Heavy Periods Consultation

Have you ever previously been diagnosed with heavy periods by a GP or any other healthcare professional?

Do your menstrual cycles follow a regular pattern each month?

Does your period currently regularly last more than 7 days?

Do you suffer with any of the following symptoms?
- Bleeding between periods

- Irregular menstrual (period) bleeding (e.g. a very heavy month followed by a light month)

- Passing large blood clots

- Passing large amounts of blood during your period and feeling faint as a result during your period

- Any other discharge from genital areas

- Blood in the urine

Do you or your family have any history of endometriosis?

Have you recently suffered with any unexplained weight loss and/or a change in bowel habits?

Have you ever been informed that any form of contraception is not suitable for you?

Have you ever previously used any treatments for your heavy periods?

Is there any possibility you may have a sexually transmitted infection? (e.g. recent unprotected sexual intercourse with somebody who is not a long term partner)

Do you suffer with any allergies or allergies to any medications?

Are you currently taking any medications? This includes prescription only medication, over the counter medication and herbal medication

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Is there any other information you would like to share with our team?

We strongly recommend that you inform your GP of any treatment you receive. Would you like Simply Meds Direct to do this on your behalf?

Do you agree to the following?
- I am between the ages of 18 and 75

- This treatment is for my use only

- I have the capacity to make decisions about my own healthcare

- I have understood all the questions and have answered this consultation truthfully and completely

- I understand the prescriber will use my answers and base their prescribing decisions accordingly, and that providing incorrect information could be harmful to my health

- I will read the patient information leaflet supplied with this medication

- I will contact we prescribe and inform my GP if I experience any side effects from this treatment or if there are any changes to my health

- I have read, understood and agree with our Terms and Conditions