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Period Pain

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 enquiries@thefamilychemist.co.uk

About You

1. Are you purchasing this medication for yourself?
2. Are you female and over 18 years old?

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

Please tell us how many weeks pregnant you are:

Medical History

4. Do you suffer from painful periods?

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

Please provide more details:

6. Do you experience any of the following?

Pain during sex
Bleeding or spotting in between period
Bleeding or spotting after sex
Abnormally heavy periods
Unusual vaginal discharge
None of the above

Please provide more details:

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

Please provide more details:

8. Does your pain completely disappear after your periods?

Please provide more details:

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

Please provide more details:

Past Medical History

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

Please provide more details:

11. 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)

Please provide more details:

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

Please provide more details:

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

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?

Please provide more details:

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

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 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 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.

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

Please click "Yes".