Period Delay - Consultation

Are you female?

Are you taking any type of hormonal contraceptives (e.g. oral or injections)?

Are you currently taking any of the following medication (including over the counter, prescription or recreational drugs)?

Medicines to treat epilepsy (e.g. phenytoin, carbamazepine) Antibiotic medicines to treat an infection (e.g. tetracyclines, rifampicin, co-trimoxazole) Antiviral medicines to treat HIV (e.g. ritonavir, nelfinavir) Anticancer medicines Herbal preparations containing St John's Wort (Hypericum perforatum) Aminoglutethimide, sometimes used in Cushing's syndrome Ciclosporin (for suppressing the immune system) Non-steroidal inflammatory drugs (NSAIDs) for treating pain and inflammation Medicines for high blood pressure Rifamycin Warfarin Sex hormones A statin for high cholesterol griseofulvin

Do you understand that this medication should be only be used for delaying your period?

Do you agree to the following?

You will read the patient information leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment. The treatment is solely for your own use You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Are you breast feeding or pregnant or possibly pregnant?

Do you have an allergy (hypersensitivity) to norethisterone?

Do you or your family members have a history of deep vein thrombosis (DVT)?

Have you been diagnosed with any of the following?

irregular vaginal bleeding of unknown cause diabetes depression epilepsy, migraine, asthma, kidney or heart problems myocardial infarction (heart attack) High blood pressure Angina Any liver disease or disturbance of liver function jaundice or herpes during pregnancy severe itching porphyria (a rare metabolic disorder) Dubin-Johnson Syndrome (chronic jaundice (yellowing of the skin or eyes)) or Rotor Syndrome (jaundice in childhood) an inherited disorder of the red blood pigment haemoglobin (porphyria) cancer of the breast or genital tract any serious medical condition which may require immediate hospitalisation