Period Delay Questions

About you

Are you 18 years of age or older?

Are you female?

Can you predict when your periods are due?

Do you or have you suffered from any heart problems stroke, angina or any other heart related problems ?

Are you taking any medication that has been prescribed by your Gp/Doctor or Hospital ?

Do you give consent for us to contact you GP if required? (we need this to process any order for medication)

Your Current Health

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

Are you pregnant or planning to become pregnant within the next six months?

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?

Are you taking any of the following medications?

  • Medicines to treat epilepsy (e.g. phenytoin, carbamazepine)
  • Antibiotic medicines to treat an infection (e.g. tetracyclines, rifampicin, co-trimoxazole)
  • Antiviral medicines to treat HIV (e.g. ritonavir, nelfinavir)
  • Anticancer medicines
  • Herbal preparations containing St John's Wort (Hypericum perforatum)
  • Aminoglutethimide, sometimes used in Cushing's syndrome
  • Ciclosporin (for suppressing the immune system)
  • Non-steroidal inflammatory drugs (NSAIDs) for treating pain and inflammation
  • Medicines for high blood pressure
  • Rifamycin
  • Warfarin
  • Sex hormones
  • A statin for high cholesterol
  • Griseofulvin

Have you been diagnosed with any of the following?

  • irregular vaginal bleeding of unknown cause
  • diabetes
  • depression
  • epilepsy, migraine, asthma, kidney or heart problems
  • myocardial infarction (heart attack)
  • High blood pressure
  • Angina
  • Any liver disease or disturbance of liver function
  • jaundice or herpes during pregnancy
  • severe itching
  • porphyria (a rare metabolic disorder)
  • Dubin-Johnson Syndrome (chronic jaundice (yellowing of the skin or eyes)) or Rotor Syndrome (jaundice in childhood)
  • an inherited disorder of the red blood pigment haemoglobin (porphyria)
  • cancer of the breast or genital tract
  • any serious medical condition which may require immediate hospitalisation

Are you taking any type of hormonal contraceptives (e.g. oral or injections)?


Do you agree to the following statements?

  • You must read the patient information leaflet supplied with your medication
  • You must contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use only.
  • You have answered all the questions in this short medical assessment accurately and truthfully to the best of your knowledge. You understand our doctor take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
all of our tests and treatments are price competative

You need to complete our short medical questionnaire so we can ensure the treatment you have selected is safe for you to use

all of our tests and treatments are price competative

Need Help?

If you need help with this medical questionnnaire call us on 07549286701

quality products assured across youth revisited

Quality products

all of our tests and treatments are price competative

Affordable prices

all of our pharmacies and and treatments purchased are from well known and trusted UK pharmacies

UK pharmacy

all of our tests and any other products purchased will be dispatched for a next day service

Express next day delivery

If you have any further questions about any of our products please feel free to contact us and we will do our best to help you.
Once you have your prescription we will be able to process your order through our trusted UK Pharmacy.