Are you registered with a GP practice in the UK?

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?
(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare?

Are you female?

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
• transient ischaemic attack(TIA), stroke (please put below myocardial infarction (heart attack)
• High blood pressure
• Angina
• Disorders that increase the risk of blood clots in the veins e.g. antiphospholipid syndrome, antithrombin deficiency or factor V Leiden systemic Lupus Erythematosus (SLE)
• Rare hereditary disorders of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption.
• 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

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

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

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.