Name *

First Name

Last Name

Do you have any concerns about your relationship or sexual partners that you wish to discuss privately with a healthcare professional?

This can include if you are being pressured into ordering medication against your will or any other concerns that you feel may be putting you at risk.

Yes

no

Are you between 18 and 55 years of age?

yes

no

What is your blood pressure?

You must have had your blood pressure checked within the last 6 months, and be aware of the results. You are able to get your blood pressure checked at your GP surgery, or your local pharmacy. Can you please let us know what your latest blood pressure reading was. If you have not had your blood pressure checked within the last 6 months, you should have this checked. If you are unsure, please let us know.

Regular (90 over 60mmHg to 140 over 90mmHg)

Low (less than 90 over 60mmHg)

High (Over 140 over 90mmHg)

Not sure

Was there anything abnormal about your last period?

yes

no

Are you currently using any female sex hormones or contraception?

yes

no

We are only able to prescribe this medication for women wanting to temporarily delay their period. Would you like to use Norethisterone to delay you period?

yes

no

Have you ever used Norethisterone before?

yes

no

Are you pregnant, breastfeeding, planning pregnancy, or at risk of pregnancy whilst taking this medication?

Pregnancy risk may be defined as late period or unprotected sexual intercourse which may have taken place since your last normal period.

Yes

No

Do any of the following apply to you?

You will be travelling for 8 hours or more, where you are likely to be immobile for most of the journey

You have diabetes

You smoke

You suffer from migraines

You have high cholesterol

Your parents have a history of heart disease, stroke or breast cancer

None of the above apply

Do any of the following apply to you?

- You have a history or family history of VTE (venous thromboembolism), or any blood clotting - You have antiphospholipid syndrome - You have a condition which affects the way your blood clots, such as factor V Leiden, protein C or S deficiency, antithrombin deficiency, antiphospholipid deficiency, thrombophilia - You have a history of heart problems such as arrythmias, heart failure, heart disease, angina, or you have had a heart attack - You have a history of high blood pressure - You have a history of blood cancer, breast cancer, cervical cancer, ovarian cancer, or any other cancer - You have a history of lung disease - You have a BMI over 35 - You have disease of the arteries - You are a smoker over the age of 35 - You have had a stroke - You have recently had surgery within the last 2 months, or due to have surgery soon - You have had a child within the last 3 months - You have a history of Crohn’s disease or Ulcerative colitis - You have rheumatoid arthritis - You have any other conditions affecting your immune system such as systemic lupus erythematosus - You have a history of varicose veins - You are immobile or bed bound - You have recently had a serious infection - You have liver problems or kidney problems - You have a history of undiagnosed vaginal bleeding - You have a history of acute porphyria or any inherited blood disorders - You have a history during pregnancy of jaundice, severe itching or skin blistering - You have a history of repeated miscarriage - You have epilepsy - You have severe itching all over your body

Yes

No

Do you have any other medical conditions?

Yes

No

Are you taking any other medication?

Yes

No

Do you have any other allergies?

Yes

No

Do you understand that you should stop taking Norethisterone and seek urgent medical advice if you experience:

- Swelling of your legs or along a vein in the leg or foot. Especially when this is accompanied by pain or tenderness in the leg, increased warmth in your leg, changes in colour of your skin on your leg - Sudden breathlessness or rapid breathing, sudden cough which may be blood stained, sharp chest pain, severe dizziness, wheezing or light headedness, rapid or irregular heartbeat - Severe stomach pain - Chest pain or discomfort in your chest or arm such as fullness, indigestion or choking feeling, sweating, nausea, vomiting or dizziness - Extreme weakness or numbness of your body, anxiety, or shortness of breath - Sudden confusion, trouble speaking or understanding - Sudden partial or complete loss of vision - Loss of balance or coordination - Fainting or seizures - Yellowing of the skin, eyes and/or darkening of the urine - Itching on your whole body - You notice any unexplained vaginal bleeding, pelvic pain or painful sex - Your mood changes - Increased frequency, length or severity of headaches - Sudden disturbance of sight or hearing (or any other perceptual disorders) - Abnormal or involuntary movements - A marked increase in blood pressure - You think you are pregnant - You notice any changes to your breasts - You notice any signs of an allergic reaction such as swelling of the face, lips, mouth, tongue or throat - You experience any other unusual side effects - This includes lactose intolerance as norethisterone tablets contain lactose.

Yes

No

Are you aware that:

- You should take one tablet three times a day, starting three days before your expected onset of period - You should not use this medication if you are at risk of pregnancy - If you do not start taking norethisterone at least 3 days before a period, it may not work to delay the period - Period bleeding usually restarts 2 to 3 days after norethisterone is stopped, but it can restart earlier after stopping - Norethisterone should only be used to delay the period temporarily - Norethisterone should not be used as a method of contraceptive cover - You should read the Patient Information Leaflet for common side effects, and report any side effects and changes in your health and body to your GP, and via the Yellow Card Scheme *Whilst you should seek urgent medical advice, you should also inform your GP and inform us if you experience any of the above. You should call 999 in the case of a medical emergency, or 111 for advice*

Yes

No

Do you agree that:

- You will read the Patient Information Leaflet supplied with your medication - You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical status changes during treatment. - You are over 18 and the treatment is solely for your own use - You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health - You are aware the decision about your treatment are for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber's - You will inform your GP that you have ordered this medication - By continuing, you agree to our Terms & Conditions and Privacy Policy

Yes

No