Period Pain Assessment

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

STOP. This consultation must be filled in by the female patient.

Yes No

3. Are you female and over 18 years old?

The Family Chemist does not supply Period Pain medication to men or under 18s. Stop and see your GP.

Yes No

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

Yes No

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

Medical History

5. Do you suffer from painful periods?

This consultation is only for treating painful periods. Please contact The Family Chemist @ enquiries@thefamilychemist.co.uk for more information.

Yes No

6. Have you ever seen a doctor about your painful periods?

Yes No

6b. Please provide us more details.

7. Do you experience any of the following?

None of the below

Pain during sex

Bleeding or spotting in between period

Bleeding or spotting after sex

Abnormally heavy periods

Unusual vaginal discharge

Other

8. Have any of your usual menstrual symptoms changed recently?

Yes No

8b. Please provide more details

9. Does your pain completely disappear after your periods?

Yes No

9b. Please provide more details

10. Do you have any other symptoms alongside period pain?

Yes No

10b. Please provide more details

Past Medical History

11. Do you suffer from lower abdominal swelling or swelling in your genitals?

Yes No

11b. Please provide more details

12. Have you ever been diagnosed with:

Peptic ulcers (i.e. stomach or small intestinal ulcers) or been told you have had a gastrointestinal bleed

Asthma

Heart failure (also called congestive cardiac failure or CCF)

Problems with your kidneys or liver

Inflammatory bowel disease (such as Crohn's or Ulcerative Colitis)

None of the above

13. Have you ever experienced an adverse reaction to, or had an issue taking, non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or aspirin?

Yes No

13b. Please provide more details

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

Yes No

14b. Please provide more details

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

Yes No

15b. Please provide more details

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

Yes No

16b. Please provide more details:

Please Provide GP Email (preferred):

Unable to find your surgery? Click Here

17. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at enquiries@thefamilychemist.co.uk so we can talk through your options.

You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
You agree to take omeprazole or other gastro-protective medicines whilst taking Naproxen.
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. Patient information leaflet: Naproxen and Mefenamic Acid.
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 No

18. 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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Period Pain Assessment

About You

Medical History

Past Medical History

0115 850 1944

enquiries@thefamilychemist.co.uk

Unit 1, Wilford Business Park,
Ruddington Lane,
Nottingham,
NG11 7EP

Opening times

Today’s Responsible Pharmacist

About You

Medical History

Past Medical History

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