Heavy Periods Assessment

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

Only the patient should be filling in the consultation.

Do not order medication for another patient or order multiple medications for different patients on a SINGLE order. Please register separate accounts for each patient as each account is treated as a medical record.

Yes No

3. Are you aged 18-45?

We cannot provide treatment to those under 18 or over 45 years of age. Please contact your GP for support.

Yes No

4. Are you breastfeeding, pregnant or planning to become pregnant?

Yes No

4b. Please tell us whether you are breastfeeding or pregnant (and how many weeks)?

5. Do you have a regular menstrual cycle (e.g. time from the 1st day of your period, to the 1st day of period the following month is normally 21 to 35 days with no more than 3 days variability between them)?

Please make an appointment with your GP to discuss your health and symptoms.

Yes No

6. Do you have any of the following symptoms?

Bleeding through your clothes or onto bedding at night

Use double sanitary products (e.g. tampon and pads)

Need to change sanitary products every 2 hrs or more often

Periods that prevent you from doing your normal activities

None of the above

7. Do you have, or have you ever had, any of the following symptoms?

Severe period pain
Bleeding between periods or after sex
Pain during intercourse
Pelvic mass with unexplained bleeding or weight loss

Yes No

7b. Please provide more details:

8. Do you have, or have you ever had, any of the following conditions?

This medication may not be suitable for you. Please contact your GP for review of your symptoms and support.

Ascites (abnormal fluid retention in the abdomen)
Diabetes
Personal or family history of blood clots or bleeding problems
Personal or family history of Polycystic ovarian syndrome (PCOS)
Seizures/epilepsy
Fibroids
Abnormal cervical screening results
Personal or family history of endometrial cancer
Iron deficiency anaemia (unresponsive to treatment)
Obesity (BMI over 30)
Liver disease
Kidney disease
Blood in urine

Yes No

9. Are you currently taking, or recently stopped taking any medicines (including over-the-counter medicines, herbal medicines or recreational drugs) - including any of the ones listed below?

Combined oral contraceptives
Epilepsy treatment
Tamoxifen
Oestrogen/ HRT
Anticoagulants (a.k.a. blood thinners) such as Warfarin, Apixaban, Rivaroxaban, Edoxaban, Dabigatran or injections for blood thinners
Fibrinolytic medications (e.g. drugs that dissolve blood clots) such as Streptokinase

Yes No

9b. Please provide more detail:

10. Do you have any other medical condition(s) or past surgical procedures?

Yes No

10b. Please provide more details:

11. Do you have any allergies to medicines or substances (e.g. peanuts, soya etc.) or to tranexamic acid?

Yes No

11b. Please provide more details:

12. Would you like us to pass on details of your treatment to your GP?

Yes No

12b. Please provide your GP's details:

Please Provide GP Email (preferred):

Unable to find your surgery? Click Here

13. Do you give consent for our clinical team to check your NHS Summary Care Records if required?

Yes

14. Do you agree with the following?

You have read the information available on the treatments and medication web page and understand the side effects, effectiveness and alternatives available.
You have answered the questions honestly and accurately and the treatment is solely for your personal use.
You will read and understand the patient information leaflet supplied with your medication.
You understand that although it is not compulsory it is important to inform your GP of this treatment so they can provide safe healthcare.
You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

Yes

15. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.

Yes

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Heavy Periods Assessment

About You

Your Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

13 Poplars Court,
Nottingham,
NG7 2RR

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Today’s Responsible Pharmacist

About You

Your Medical History

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