About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Please state your gender
This refers to your biological gender
Date of Birth
Use the calendar to select your date of birth.
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
Please add your height (in cms).
Your height is important for the prescribers decision.
Please add your current weight (in kgs).
Please make sure to add your current weight. This may affect the prescriber's decision.
Women only: Are you pregnant or is there a possibility you may be pregnant?
If you are male, answer No
Women only: Are you breast feeding?
Are you allergic to norethisterone or any other similar hormone medicines?
If yes, please provide details
Do you or your family have any current or previous bleeding disorders? This includes (but is not limited to):
Deep vein thrombosis (DVT) and Pulmonary embolism
Do you have any liver problems?
If yes, please provide details
Do you have any heart problems? This includes (but is not limited to):
- Angina
Do you have high cholesterol, or do you smoke?
Have you previously suffered from jaundice, chloasma or preeclamptic toxaemia (high blood pressure) during pregnancy?
Have you ever had any surgery (operations)?
If so, please provide more details
Do you have endometrial hyperplasia (thickening of uterus lining)?
Have you been told by your doctor that you have an intolerance to any sugars?
E.g. fructose intolerance, glucose-galactose malabsorption, or sucrase-isomaltase insufficiency
Do you have known or suspected cancer, or have you had cancer in the past?
If yes, please provide details
Have you previously had a transient ischaemic attack (mini stroke) or stroke?
Do you suffer from severe pruritus (itchy skin all over the body)?
Do you have porphyria or jaundice?
Have you previously had severe pruritus or pemphigoid gestationis (an itchy rash) during pregnancy?
Are you currently using any form of contraception?
If yes, please provide details e.g. which pill, patch or other method
Do you have any eye problems? This includes:
Papilloedema and Retinal vascular lesions
Do you have any kidney problems?
If yes, please provide details
Do you have any of the following:
Migraines / Epilepsy / Asthma
Do you or your close family have any of the following:
Systemic lupus erythematosus / Severe obesity (BMI >30 kg/m2) / Thromboembolism / Recurrent miscarriage
Are you being treated with steroid hormones?
Have you been immobile for a prolonged time (bed rest) or are you due to receive surgery?
If yes, please provide details
Do you have any allergies?
If yes, please provide details
Do you have severe depression, generalized anxiety disorder or any other psychiatric disorder?
Do you have inflammation of your veins (superficial phlebitis) or varicose veins?
Why do you want to delay your period?
Please provide details of any recent or past medical history of note
Please list all your current prescription medication including any medication you buy over the counter (including enzyme inducers)
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