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Period Delay Questionnaires

Period delay

Patient details

Warning: This service is ONLY for women (up to 54 years) to delay the period!

Please complete the consultation as accurately as possible.

Are you completing the consultation for yourself?

Yes

No

What is your name?

Who are you ordering for?

First Name

Last Name

Date of birth

Email

Address

City

Postcode

Is the shipping address the same as above?

Yes

No

What is your shipping address?

Are you allergic or sensitive to norethisterone?

Yes

No

We are unable to supply norethisterone. Please consult your GP.

Are you pregnant, possibly pregnant, or breastfeeding?

Yes

No

We are unable to supply norethisterone. Please consult your GP.

Are you using any hormonal contraception?

Yes

No

We are unable to supply norethisterone. Please consult your GP.

Do you belong to a high-risk category for thrombosis, also known as DVT or blood clots?
This may include being significantly overweight, having a history of blood clots in veins or lungs, having relatives with a history of blood clots, experiencing prolonged immobility (such as after surgery or during extended flights of 6 hours or more), undergoing major surgery, or having a history of recurrent miscarriages.

Yes

No

We are unable to supply norethisterone. Please consult your GP.

Are you over the age of 35 and currently a smoker?

Yes

No

We are unable to provide you with norethisterone. Women aged 35 and above who smoke face a slightly increased risk of thrombosis (blood clot). Please consult your GP.

Are you currently experiencing unexplained irregular vaginal bleeding that has not been diagnosed?

Yes

No

We are unable to supply norethisterone. Please consult your GP.

Are you currently using any of the following medications?
These drugs have the potential to interact with norethisterone:

Medications for epilepsy (e.g., phenytoin, carbamazepine)

Antiviral drugs for HIV treatment (e.g., ritonavir, nelfinavir, nevirapine, efavirenz)

Blood-thinning medication (e.g., warfarin)

Herbal preparations containing St John's Wort (Hypericum perforatum)

Antibiotics for tuberculosis (e.g., rifampicin, rifabutin)

Other antibiotic medicines (e.g., doxycycline, lymecycline, other tetracyclines, co-trimoxazole)

Anticancer medicines

Ciclosporin (used to suppress the immune system)

Non-steroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation

Medications for high blood pressure

Yes

No

Regrettably, we cannot provide norethisterone. Kindly seek advice from your GP for further assistance.

Have you ever been diagnosed with any of the following?

Angina (heart pain)

Myocardial infarction (heart attack)

High blood pressure

Liver disease

Jaundice in pregnancy

Severe itching or a severe blistering rash in pregnancy (rare)

Porphyria (rare metabolic disorder)

Genital or breast cancer or liver tumours

Systemic lupus erythematosus (SLE)

Diabetes

Depression

Otosclerosis (rare cause of hearing problems)

Yes

No

Regrettably, we cannot provide norethisterone. Kindly seek advice from your GP for further assistance.

Have you received a diagnosis for any of the following conditions? These conditions may be exacerbated by fluid retention, which can occasionally be caused by norethisterone: Epilepsy Migraine Asthma Heart disease Kidney disease

Yes

No

Regrettably, we cannot provide norethisterone. Kindly seek advice from your GP for further assistance.

Do you agree that norethisterone should be commenced at least 3 days before the expected period, and that the onset of period bleeding usually occurs 2-3 days after discontinuing these medications, with variations in timing?

I understand

Consent

I will read the information leaflet supplied with the tablets and read medical info on the period delay page

I have completed this questionnaire myself and fully understand all the information

I consent to the Online Chemist accessing my NHS summary care record (SCR) to process my treatment, if needed

I consent to have Online Chemist store my submitted information so they can respond to my inquiry.

Official use only

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Online Chemist in Gorleston, an NHS online pharmacy and travel vaccine clinic

Online Chemist
82 Middleton Road
Gorleston
Great Yarmouth
Norfolk, NR31 7AH
Phone: 01493 600610
Email: info@onlinechemistuk.net

Superintendent Pharmacist:
Obaidullah Zaman
BPharm, MPharm, PGDip (Pharmacy), MRPharmS, IP
GPhC Reg. Number: 2083409

Pharmacy Premises GPhC Reg. Number: 9011159

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NHS online pharmacy Gorleston Great Yarmouth Norfolk

OPENING HOURS

Monday 09:00 – 17:00
Tuesday 09:00 – 17:00
Wednesday 09:00 – 17:00
Thursday 09:00 – 17:00
Friday 09:00 – 17:00
Saturday Closed
Sunday Closed

Click here for driving directions

Online Chemist is a trading name of Nomaz Limited.
Registered in England – 11349276.

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