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Period Delay Risk Assessment Form

lets get your details sent across.

Your Details

Name

D.O.B

Sex

Male Female Non-Binary

Email

Contact Number

Address Details

First Line of Address

Second Line of Address (optional)

City

Postcode

GP Details

NHS Number (Optional)

GP/GP Practice Name

GP Address

Would you like your GP to be informed of this consultation?

Yes No

Medical Information

Are you pregnant, planning pregnancy or is there any possibility that you could be pregnant?

Yes No

Are you breast-feeding?

Yes No

Do you suffer from severe pruritus (itchy skin all over the body)?

Yes No

Have you previously had severe pruritus or pemphigoid gestationis (an itchy rash) during pregnancy?

Yes No

Do you have porphyria or jaundice?

Yes No

Are you allergic to norethisterone or any other similar hormone medicines? If yes, please provide details

Yes No

Please provide more information

Do you or your family have any current or previous bleeding disorders?

This includes (but is not limited to):
- Deep vein thrombosis (DVT)
- Pulmonary embolism

Yes No

Are you currently using any contraception?

Yes No

Please provide details of contraception

Have you ever suffered from vaginal bleeding in which no cause was found?

Yes No

Do you have any eye problems?

This includes:
- Papilloedema
- Retinal Vascular Lesions

Yes No

Do you have any liver problems?

Yes No

Please provide details

Do you have any kidney problems?

Yes No

Please provide details

Do you have any heart problems?

This includes (but is not limited to):
- Angina
- Heart Attack

Yes No

Do you have any of the following:

- Migraines
- Epilepsy
- Asthma

Yes No

Do you have High Cholesterol or do you smoke?

High Cholesterol Smoke None

Do you or your close family have any of the following:

Systemic Lupus Erythematosus Severe Obesity (BMI>30kg/m2) Thromboembolism Recurrent Miscarriage None

Have you previously suffered from jaundice, chloasma or pre-eclamptic toxaemia (high blood pressure) during pregnancy?

Yes No

Are you being treated with steroid hormones?

Yes No

Have you recently undergone major surgery or major trauma?

Yes No

Have you been immobile for a prolonged time (bed rest) or are you due to receive surgery?

Yes No

Please provide details

Do you have endometrial hyperplasia (thickening of uterus lining)?

Yes No

Do you have any allergies?

Yes No

Please provide details

Have you been told by your doctor you have an intolerance to any sugars?

Yes No

Please provide details

Do you have diabetes?

Yes No

Please list any associated problems

Do you have a known or suspected cancer, or have you had cancer in the past (e.g. breast cancer)?

Yes No

Please provide details

Do you have severe depression, generalized anxiety disorder or any other psychiatric disorder?

Yes No

Have you previously had a transient ischaemic attack (mini stroke) or stroke?

Yes No

Do you have inflammation of your veins (superficial phlebitis) or varicose veins?

Yes No

Why do you want to delay your period?

Please provide details of any recent or past medical history of note (e.g. other medical conditions that you have previously been treated for)

Please list all your current prescription medication including any medication you buy over the counter

Disclaimer

1. I have received information on the risks and benefits of the medicine, and I have had the opportunity to ask questions. The medical information I have provided is true and accurate to the best of my knowledge, and I consent to the medicine being administered.

2. I understand that my personal information, including name, surname, email, telephone, date of birth (DOB), address, NHS number, and GP details, will be securely uploaded to the Church Lane Pharmacy website for electronic storage, and it will be kept in line with data protection regulations along with the details of the consultation (i.e., medicines provided).

3. I authorise the collection, storage, and secure transmission of my information for the purposes mentioned above.

4. I acknowledge that after the consultation, the details of my medication and consultations will be accessible through my Church Lane Pharmacy account, using the provided email address for login.

5. I understand that I can speak to a member of staff about any queries regarding the Church Lane Pharmacy consultation or the processing of personal data for this consultation, including exercising my rights under data protection legislation.

Enter Your Full Name

Enter Todays Date

Disclaimer

By clicking Submit, you confirm that the information you have provided is true, accurate, and complete to the best of your knowledge. You consent to us using this information to deliver any relevant services and to securely store your details in line with data protection requirements. You also agree that we may use your contact information to communicate with you regarding any current, ongoing, or previous services or appointments with us.

Church Lane Pharmacy in Pudsey, Leeds offers trusted NHS and private healthcare services, including vaccinations, travel health, prescriptions, and expert pharmacy advice for the local community.

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Church Lane Pharmacy, 23 Church Lane, Leeds, LS28 7LD
churchlane.pharmacy@nhs.net
0113 2574629
Monday - Friday: 09:00 - 18:00
Saturday: 09:00 - 13:00

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