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Medical Assessment

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About You
Are you female?
    Norethisterone is only for female patients.
    Please complete this question.
    Your Health
    Are you breast feeding or pregnant or possibly pregnant?
      We are unable to supply you with norethisterone. Please consult your GP.
      Please complete this question.
      Do you have an allergy (hypersensitivity) to norethisterone?
        We are unable to supply you with norethisterone. Please consult your GP.
        Please complete this question.
        Do you or your family members have a history of deep vein thrombosis (DVT)?
          We are unable to supply you with norethisterone. Please consult your GP.
          Please complete this question.
          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
          We are unable to supply you with norethisterone. Please consult your GP.
          Please complete this question.
          Your Medication
          Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
          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
          We are unable to supply you with treatment. Please consult your GP or doctor for more information.
          Please complete this question.
          Are you taking any type of hormonal contraceptives (e.g. oral or injections)?
            We are unable to supply you with norethisterone. Please consult your GP.
            Please complete this question.
            Agreement
            Do you understand that this medication should be only be used for delaying your period?
              We can only supply Norethisterone for period delay. If you would like to take this medication for any other reason, you must make an appointment to see your doctor as the treatment recommended may be different.
              Please complete this question.
              Do you agree to the following?
              • You will read the patient information leaflet supplied with your medication
              • You will contact us and inform your GP of your medication if you experience any side effects of treatment, you start new medication and/or your medical conditions change during treatment
              • The treatment is solely for your own use
              • You have answered all the above questions accurately and truthfully
              • You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
              • You understand that whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber
              You must agree to this before continuing. If you need assistance contact our customer support.
              Please complete this question.
              Complete our 2 minute questionnaire
              We’re almost done!
              Ana Carolina Osorio De Faria Goncalves
              To find a treatment suitable for you, we just need you to answer a few questions.
              Ana Carolina Goncalves
              Superintendent Pharmacist
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              Lowest Price Guarantee

              We're so confident you won't find your treatment cheaper, that if you do, we'll refund the difference for up to 14 days!

              Need help?

              If you need help with this medical assessment, contact our helpline:

              0207 112 9014

              or email us:

              help@pharmica.co.uk
              Fully Regulated

              We are regulated by the General Pharmaceutical Council

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