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 answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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We need a recent blood pressure measurement because some period delay medications can increase your risk
of blood clots. We will consider your blood pressure and the other information you provide to decide if it’s safe
for them to prescribe you this medication.



For example, do you bleed between periods or after you have sex, or are your periods very heavy or painful?

If yes, have you discussed this bleeding with your GP or a gynaecologist? What did the doctor advise was
causing the bleeding? Has the bleeding changed since you last spoke to your doctor?


  • endometrial hyperplasia (thickening of uterus lining)
  • diabetes
  • high cholesterol
  • depression
  • epilepsy, migraine, asthma, kidney or heart problems
  • myocardial infarction (heart attack)
  • stroke
  • high blood pressure
  • angina
  • any liver disease or disturbance of liver function
  • jaundice or high blood pressure 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.

If yes, provide information.


If yes, please provide details.



If yes, provide information on why do you need a further prescription for period delay medication.




Combined pills, patches and rings are contraceptives that have a combination of two hormones. You typically
have 4-7 days without hormones when you have a period or bleed. Mini pills contain only progesterone (like
desogestrel, Cerazette or Cerelle), which you take continuously without a break.

No
Yes, I use a combined pill, patch or ring.
Yes, I use a mini pill, implant, injection or coil.



E.g. fructose intolerance, glucose-galactose malabsorption, or sucrase-isomaltase insufficiency




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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.