Delay Period Questionnaire | Mind Your Own Rx

Delay Period Purchased

When was the first day of your last period?

Are your periods regular?

Yes

When was the last time you were seen by OB/Gyn?

More than 1 year ago

Less than 1 year ago

Please be assessed by your GYN provider in person for a full exam including assessment for endometrial cancer.

Are you breastfeeding?

Yes

FYI: Norethindrone is present in breast milk. Isolated reports of decreased milk production and very rare reports of jaundice in breastfeeding infants have been noted. In general, adverse events related to infant growth and development have not been reported.

Have you recently used emergency contraception?

Yes

FYI: use of emergency contraception and norethindrone within a few days of each other will make both medications less effective.

Are you taking any of the following medication: rifampin, carbamazepine, phenytoin, oxcarbazepine, primidone, topiramate, griseofulvin, ketoconazole, ritonavir, ombitasivir, paritaprevir, dasabuvir, St. john's wart, saw palmetto, alfalfa, garlic pills, flax seed, HIV meds, or modanafil?

Yes

FYI: Norethindrone may be less effective when taking any of the listed medication.

Do you have a history of the following: Breast CA, blood clots such as a deep vein thrombosis or pulmonary embolism? (This does not include heavy vaginal bleeding with clots.)

Yes

Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.

Do you smoke?

Yes

It is important for me to counsel you regarding the following: Tobacco and tobacco-product use can put you at risk for stroke, heart attack, and other cardiovascular conditions. It is recommended that you avoid use of these products.

Information about yourself

Gender assigned at birth

Male

Female

Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.

Are you pregnant?

Yes

Unfortunately, we are unable to provide this service for you. Please see your provider in person for care.

First Name

Last Name

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