Rxpress

Norethisterone for Period Delay
Risk Assessment Form

Title:
—Please choose an option—MrMissMsMrsOther

Date of Birth (DD/MM/YY):

Age:

Name:

Surname:

Home Address:

Email:

Telephone:

Name & Address of GP (optional):

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

Please answer the following questions

Are you pregnant, planning pregnancy, or could you be pregnant?
YesNo

Are you breast-feeding?
YesNo

Do you have porphyria or jaundice?
YesNo

Are you allergic to norethisterone or similar hormone medicines?
YesNo

If yes, please provide details:

Do you suffer from severe pruritus (itchy skin all over the body)?
YesNo

Have you had severe pruritus or pemphigoid gestationis during pregnancy?
YesNo

Do you or your family have any bleeding disorders? (e.g., DVT, Pulmonary embolism)
YesNo

Are you currently using any contraception?
YesNo

If yes, please provide details:

Have you ever had unexplained vaginal bleeding?
YesNo

Do you have any eye problems (e.g., Papilloedema, Retinal vascular lesions)?
YesNo

Do you have any liver problems?
YesNo

If yes, please provide details:

Do you have any kidney problems?
YesNo

If yes, please provide details:

Do you have any heart problems (e.g., Angina, Heart attack)?
YesNo

Do you have any of the following? (tick all that apply)
MigrainesEpilepsyAsthma

Do you have high cholesterol, or do you smoke?
YesNo

Do you or your close family have any of the following?
Systemic lupus erythematosusSevere obesity (BMI >30)ThromboembolismRecurrent miscarriage

Have you previously had jaundice, chloasma, or pre-eclamptic toxaemia during pregnancy?
YesNo

Are you being treated with steroid hormones?
YesNo

Have you recently undergone major surgery or major trauma?
YesNo

Have you been immobile for a prolonged time or are you due to receive surgery?
YesNo

If yes, please provide details:

Do you have endometrial hyperplasia (thickening of uterus lining)?
YesNo

Do you have any allergies?
YesNo

If yes, please provide details:

Have you been told by your doctor you are intolerant to any sugars?
YesNo

If yes, please provide details:

Do you have diabetes?
YesNo

If yes, please list any associated problems:

Do you have a known or suspected cancer, or have you had cancer in the past (e.g. breast cancer)?
YesNo

If yes, please provide details:

Do you have severe depression, generalized anxiety disorder, or other psychiatric disorders?
YesNo

Have you previously had a TIA (mini stroke) or stroke?
YesNo

Do you have inflammation of your veins (e.g., superficial phlebitis or varicose veins)?
YesNo

Why do you want to delay your period?

Medical history (recent or past):

List all current medications (prescribed, OTC, including enzyme inducers):

Do we have permission to access your medical records?
YesNo