1. Have you read information about delaying a period on Patient.info?

Yes

No

2. Please specify why you would like to delay your period:

3. What was the start date of your last period?

4. Are you allergic or sensitive to norethisterone?

Yes

No

5. Are you pregnant or possibly pregnant?

• Norethisterone is not recommended in pregnancy

Yes

No

6. Are you taking contraceptive pills of any type?

Yes

No

7. Are you using hormone injections for contraception?

Yes

No

8. Have you had a thrombosis (DVT) or does thrombosis run in your family?

• Also sometime called blood clots, usually in the calves of the legs.

Yes

No

9. Are you over 35 AND a smoker?

Yes

No

10. Do you have undiagnosed irregular vaginal bleeding

Yes

No

11. Have you been diagnosed with any of the following?

• angina (heart pain)
• myocardial infarction (heart attack)
• high blood pressure
• liver disease
• jaundice in pregnancy
• severe itching or a severe blistering rash in pregnancy (rare)
• porphyria (rare metabolic disorder)

Yes

No

12. Do all of the following apply to you?

• I will read the patient information leaflet supplied with my medication.
• The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)

Yes

No