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period pain

We understand how debilitating period pain can be it’s more than just cramps; it can seriously disrupt your daily life. While over-the-counter treatments like ibuprofen or paracetamol work for some, they’re often not enough for those with more severe symptoms. If you’re struggling, we can offer stronger, prescription-strength options that may provide the relief you need to feel like yourself again.

Period Pain Relief Consultation Form

Full name:

Date of Birth (DD/MM/YYYY):

Age:

Home Address:

Email:

Telephone:

NHS number (optional):

Name & Address of GP:

Would you like your GP to be informed of this consultation?
YesNo

Medical Questions

Do you have any allergies?
YesNo

If yes, please describe the allergy/reaction:

Do you have any recent or past medical history of note?
YesNo

If yes, please provide details:

Have you ever had an allergic or anaphylactic reaction to naproxen, aspirin, ibuprofen or any other medication?
YesNo

If yes, please provide details:

Do you have any liver problems?
YesNo

If yes, please provide details:

Are you pregnant, planning pregnancy or is there a possibility you may be pregnant?
YesNo

If yes, please provide details:

Do you have kidney problems?
YesNo

If yes, please provide details:

Are you currently breast-feeding?
YesNo

Have you been told by your doctor you have an intolerance to any sugars (e.g. galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
YesNo

If yes, please provide details:

Do you have any problems with your stomach or gut (intestine), such as an ulcer or bleeding?
YesNo

If yes, please provide details:

Do you have any heart problems?
YesNo

If yes, please provide details:

Do you have high blood pressure, diabetes, high cholesterol or are you a smoker?
YesNo

If yes, please provide details:

Do you have difficulties conceiving or are you undergoing investigation of fertility?
YesNo

Do you have a history of gastrointestinal diseases such as ulcerative colitis or Crohn’s disease?
YesNo

Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?
YesNo

If yes, please provide details:

Do you have asthma, allergies (like hay fever), polyps or rhinitis?
YesNo

Do you have any autoimmune condition such as systemic lupus erythematosus?
YesNo

Do you have any symptoms?
YesNo

If yes, please provide details:

Please list all your current prescription medication including any medication you buy over the counter:

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