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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Women only: Are you pregnant or is there a possibility you may be pregnant?
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 and heart attack
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 recently undergone major surgery or major trauma?
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 a known or suspected cancer, or have you had cancer in the past (e.g. breast cancer)?
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 contraception?
If yes, please provide details
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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