Name
*
First Name
Last Name
Date Of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
What date is your period due to start?
*
MM
DD
YYYY
What date do you want to delay your period until?
*
MM
DD
YYYY
Is your menstrual cycle regular (every 21–35 days)?
*
Yes
No
Do you know the usual length of your cycle?
*
Yes
No
If yes, how many days is your usual cycle?
Are you currently pregnant or think you could be?
*
Yes
No
Are you currently breastfeeding?
*
Yes
No
Have you had any unexplained vaginal bleeding in the past 3 months?
*
Yes
No
Have you ever been diagnosed with breast cancer, liver disease, or porphyria?
*
Yes
No
Do you have a history of blood clots (e.g., DVT, PE, stroke) or a family history of clotting disorders?
*
Yes
No
Have you had a recent major surgery, or will you be immobile for a long period?
*
Yes
No
Do you smoke?
*
Yes – over 15/day
Yes – under 15/day
No
Are you currently using hormonal contraception (pill, implant, coil, injection)?
*
Yes
No
If yes, please list the type and when you started it
Have you used norethisterone or other period delay tablets before?
*
Yes
No
Are you currently taking any prescribed or over-the-counter medications?
*
Yes
No
If yes, please list them (include supplements or herbal remedies)
Have you experienced side effects with them before?
*
Yes
No
Do you have any allergies to medications?
*
Yes
No
If yes, please specify
Do you have a history of: high blood pressure, migraines with aura, diabetes, liver/kidney problems, or epilepsy?
*
Yes
No
Are you registered with a UK GP?
*
Yes
No
GP Surgery Name
Would you like a summary shared with your GP?
*
Yes
No
Consent & Declaration
*
