• Periods
  • History
  • Medicines
  • Measurements
  • Consent
Our doctors would now like to check your suitability for this product

Your Periods

Why do you wish to delay your period?

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)?

Can you predict when your periods are due?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Your medical history

Have you ever had a stroke, a blood clot in your legs or lungs, a heart attack or any heart problem?

Do you have a history of high blood pressure or are you on treatment for high blood pressure?

Do you have high cholesterol levels?

Do you have sickle cell disease (not sickle cell trait)?

Have you ever been diagnosed with a liver condition?

Have you ever had a serious brain injury, been diagnosed with epilepsy or suffer from seizures?

Have you ever suffered from migraines or severe headaches?

Have you experienced new or worsening migraine or severe headache symptoms while on a combined contraceptive?

Have you ever had cancer?

Have you ever been diagnosed with diabetes or abnormal blood sugar levels?

Are you due to have any major surgery or have you had major surgery in the past three months?

Do you have any problems with your mobility?

Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?


Pregnancy and breastfeeding

How do I know if I\'m pregnant?

Have you ever been pregnant?


Your family history

Has anyone in your family ever had a blood clot in the legs or lungs?

Has anyone in your family ever had a heart attack or stroke?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Current and recent use of medicines

Are you taking any prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?

Are you currently using a hormonal contraceptive?


Allergies

Are you allergic to any of the following? Please select all that apply.

Do you have any other known allergies?


Smoking

Do you smoke?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Your height and weight

Please enter your height(cm).

Please enter your weight(kg).

What is your blood pressure?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

I confirm the above statements are true --I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the doctor can safely assess and advise me.
--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Your Chemist Online Doctor before proceeding.
--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
--I have read, understand and agree to the latest terms and conditions and privacy policy


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