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Your Health

About You

Do you believe you have the capacity to make decisions about your own health; and that you do not require help to complete this consultation? *

Yes

Do you have any concerns about your relationship or sexual partner(s) that you wish to discuss privately with a healthcare professional? *

Yes

This can include if you are being pressured into ordering medication against your will or any other concerns that you feel may be putting you at risk. Support is available from Women’s Aid.

What is your height? *

feet/inches

cm *

What is your weight? *

stones/lb

kg *

Stone *

Are you between 18 and 55 years of age? *

Yes

What is your blood pressure? *

You must have had your blood pressure checked within the last 6 months, and be aware of the results. You are able to get your blood pressure checked at your GP surgery, or your local pharmacy. Can you please let us know what your latest blood pressure reading was. If you have not had your blood pressure checked within the last 6 months, you should have this checked. If you are unsure, please let us know.

Regular (90 over 60mmHg to 140 over 90mmHg)

Low (less than 90 over 60mmHg)

High (Over 140 over 90mmHg)

Not Sure

Your symptoms

Was there anything abnormal about your last period? *

Yes

Are you currently using any female sex hormones or contraception? *

Yes

We are only able to prescribe this medication for women wanting to temporarily delay their period. Would you like to use norethisterone to delay your period? *

Yes

Have you ever used norethisterone before? *

Yes

Your health

Are you pregnant, breastfeeding, planning pregnancy or at risk of pregnancy whilst taking this medication? *

Yes

Pregnancy risk may be defined as late period or unprotected sexual intercourse which may have taken place since your last normal period.

Do any of the following apply to you? *

You will be travelling for 8 hours or more, where you are likely to be immobile for most of the journey

You have diabetes

You smoke

You suffer from migraines

You have high cholesterol

Your parents have a history of heart disease, stroke or breast cancer

None of the above apply

Do any of the following apply to you? *

Yes

You have a history or family history of VTE (venous thromboembolism), or any blood clotting
You have antiphospholipid syndrome
You have a condition which affects the way your blood clots, such as factor V Leiden, protein C or S deficiency, antithrombin deficiency, antiphospholipid deficiency, thrombophilia
You have a history of heart problems such as arrythmias, heart failure, heart disease, angina, or you have had a heart attack
You have a history of high blood pressure
You have a history of blood cancer, breast cancer, cervical cancer, ovarian cancer, or any other cancer
You have a history of lung disease
You have a BMI over 35
You have disease of the arteries
You are a smoker over the age of 35
You have had a stroke
You have recently had surgery within the last 2 months, or due to have surgery soon
You have had a child within the last 3 months
You have a history of Crohn’s disease or Ulcerative colitis
You have rheumatoid arthritis
You have any other conditions affecting your immune system such as systemic lupus erythematosus
You have a history of varicose veins
You are immobile or bed bound
You have recently had a serious infection
You have liver problems or kidney problems
You have a history of undiagnosed vaginal bleeding
You have a history of acute porphyria or any inherited blood disorders
You have a history during pregnancy of jaundice, severe itching or skin blistering
You have a history of repeated miscarriage
You have epilepsy
You have severe itching all over your body

Do you have any other medical conditions? *

Yes

Your Medication

Any you taking any medication? *

Yes

Do you have any allergies? *

Yes

Agreement

Do you understand that you should stop taking norethisterone and seek urgent medical advice if you experience: *

Yes

Swelling of your legs or along a vein in the leg or foot. Especially when this is accompanied by pain or tenderness in the leg, increased warmth in your leg, changes in colour of your skin on your leg
Sudden breathlessness or rapid breathing, sudden cough which may be blood stained, sharp chest pain, severe dizziness, wheezing or light headedness, rapid or irregular heartbeat
Severe stomach pain
Chest pain or discomfort in your chest or arm such as fullness, indigestion or choking feeling, sweating, nausea, vomiting or dizziness
Extreme weakness or numbness of your body, anxiety, or shortness of breath
Sudden confusion, trouble speaking or understanding
Sudden partial or complete loss of vision
Loss of balance or coordination
Fainting or seizures
Yellowing of the skin, eyes and/or darkening of the urine
Itching on your whole body
You notice any unexplained vaginal bleeding, pelvic pain or painful sex
Your mood changes
Increased frequency, length or severity of headaches
Sudden disturbance of sight or hearing (or any other perceptual disorders)
Abnormal or involuntary movements
A marked increase in blood pressure
You think you are pregnant
You notice any changes to your breasts
You notice any signs of an allergic reaction such as swelling of the face, lips, mouth, tongue or throat
You experience any other unusual side effects

This includes lactose intolerance as norethisterone tablets contain lactose.

Is there any additional information you would like to provide, or any questions you have? *

Yes

Are you aware that? *

Yes

You should take one tablet three times a day, starting three days before your expected onset of period
You should not use this medication if you are at risk of pregnancy
If you do not start taking norethisterone at least 3 days before a period, it may not work to delay the period
Period bleeding usually restarts 2 to 3 days after norethisterone is stopped, but it can restart earlier after stopping
Norethisterone should only be used to delay the period temporarily
Norethisterone should not be used as a method of contraceptive cover
You should read the Patient Information Leaflet for common side effects, and report any side effects and changes in your health and body to your GP, and via the Yellow Card Scheme

Whilst you should seek urgent medical advice, you should also inform your GP and inform us if you experience any of the above. You should call 999 in the case of a medical emergency, or 111 for advice.

Do you agree that? *

Yes

You will read the Patient Information Leaflet supplied with your medication
You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical status changes during treatment.
You are over 18 and the treatment is solely for your own use
You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health
You are aware the decision about your treatment are for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber's
You will inform your GP that you have ordered this medication
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