Period Delay prescription questionnaire

Name *

First

Last

Date of Birth *

Email *

Address *

Select Pharmacy to where prescriptions should be sent. Select "other" if you can't find your pharmacy *

1. Please share the reason you wish to delay your period? *

Holiday, festival or religious event
Sporting event, wedding, work meeting
Other

2. If you are flying long haul, there is an increased risk of blood clots when using the period delay medication. You can reduce risks of blood clots by exercising and wearing flight socks during the flight. *

I understand

3. Have you been experiencing any abnormal or undiagnosed vaginal bleeding (bleeding other than your period such as in between your periods or after sex?) *

4. Period delay tablets can increase your risk of blood clots. Please confirm if you have had any of the following *

A heart problem or stroke
A blood clot in your lungs or legs
Been given treatment for high blood pressure
Sickle cell disease
Porphyria
surgery in the last 3 months
Immobility (such as broken leg in the last few months)
A family member has a blood clot in their lungs or legs- Please share more information with us
None

5. Please confirm your blood pressure (taken within the last 9 months)? *

Normal (
High (>140/90)
I don’t know

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