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Period Delay Assessment

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

About You

1. Hi. What is your name?

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.

2. Are you purchasing this medication for yourself?

STOP. Do not order medication for another patient or order multiple medications for different patients on a SINGLE order. Please use separate accounts for each patient.

3. Are you female and over 18 years old?

The Family Chemist does not offer period delay medication to male patients or patients under 18 years old.

4. Are you breast feeding, pregnant or planning to become pregnant?

4b. Please tell us whether your are breastfeeding OR if you are pregnant: please tell us how many weeks pregnant you are.

5. Why do you wish to delay your period?

6. Do you experience any abnormal or undiagnosed vaginal bleeding (that is bleeding other than your period, such as bleeding in between periods or bleeding after sex)?

7. Are you currently using a hormonal contraceptive?

7b. Please provide more details:

8. What is your blood pressure?

9. Have you or your family ever had a blood in your legs or lungs (DVT or PE)?

9b. Please provide more details:

10. Have you ever been diagnosed with any of the following:

  • Stroke, bloods clot in your legs or lungs, a heart attack or any other heart problem
  • History of high blood pressure or are you on treatment for high blood pressure
  • High cholesterol
  • Sickle cell disease
  • Liver or kidney conditions
  • Asthma
  • Any form of cancer
  • Porphyria
  • a serious brain injury, been diagnosed with epilepsy or suffer from seizures
  • migraines or severe headaches
  • diabetes or abnormal blood sugar levels
  • depression
  • any major surgery or have you had major surgery in the past three months
  • Mobility issues

10b. Please provide more details:

11. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

11b. Please provide more details:

12. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

12b. Please provide more details:

13. Are you allergic to any medicines or other substances e.g. peanuts or soya?

13b. Please provide more details:

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

14b. Please find your GP below:




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15. Do you agree with the following?

  • You have read the information available on the treatments and medication web page and understand the side effects, their 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.

16. I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet.

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