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What is your biological sex? (at birth)

What is your height? (cm)

What is your weight? (Kg)

Do you need help completing this questionnaire?

Yes

Do you believe that you have the capacity to make decisions about your own healthcare?

Yes

Have you been diagnosed with any medical conditions?

Yes

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

Yes

Do you suffer from any allergies?

Yes

Do you have limited mobility or use a wheelchair?

Yes

Is there anything else you would like to include to allow our prescriber to prescribe responsibly?

Yes

Why are you requesting medication for period delay?

Are you currently using regular contraception?

Do you experience irregular bleeding or spotting between your periods?

Yes

Are you currently pregnant, breastfeeding or actively trying to have a baby?

Yes

Have you ever had migraines?

Yes

Do you ever experience severe headaches at the front and or side of your head with nausea and vomiting that is worsened by light and sound?

Yes

Have you or anyone in your family ever had a blood clot (DVT or PE) or have you had major surgery in the last 3 weeks?

DVT: Deep Vein Thrombosis, PE: Pulmonary Embolism

Yes

Have you ever suffered from any of the following conditions: Diabetes, Cancer, Kidney problems, epilepsy, liver problems or asthma?

Yes

Do you smoke?

Yes

Has your blood pressure been checked in the past year?

Yes

Do you agree to the following:

You confirm that your answers are truthful and will guide medical decisions, agree to read the medication leaflet, accept DrWeightmans terms, confirm the treatment is for personal use, and will notify your GP if needed.

Yes

To support your care, we kindly ask for your GP details. If treatment is supplied, we may notify them. Providing accurate information helps avoid any delays.

Enter GP details Manually or search via GP postcode/name.

Yes

Assessment

Period Delay Consultation

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