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0115 8501944
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0115 8501944
Bank Holiday Weekend Delivery Cut-off:
 03/05/2024 2pm for delivery on 07/05/2024
Closed for May Bank Holiday Weekend - Saturday 4th May - Monday 6th May
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Period Pain 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?

2. Are you purchasing this medication for yourself?

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

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.

4. Are you pregnant, breastfeeding or trying 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. Do you suffer from painful periods?

This consultation is only for treating painful periods. Please contact The Family Chemist @ [email protected] for more information.

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

6b. Please provide us more details.

7. Do you experience any of the following?

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

8b. Please provide more details

9. Does your pain completely disappear after your periods?

9b. Please provide more details

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

10b. Please provide more details

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

11b. Please provide more details

12. Have you ever been diagnosed with:

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?

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?

14b. Please provide more details

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

15b. Please provide more details

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

17. Do you agree with the following?

We cannot supply you with this treatment at this moment. Please contact our patient support team at [email protected] 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.

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.