Consultation - Your Pharmacy Clinics

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Question 1:Do you have any known allergies?

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Question 3:Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Question 4:Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Question 5:Do you smoke?

Question 6:Do you consume alcohol?

If yes, how much a day/weekly?

Question 7:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Balanced

High-fat

Spicy foods

Other

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

Daily

Weekly

Rarely

Never

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Question 1:Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for Period Delay.

Question 2:Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Question 3:Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Question 4:Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

Travel Vaccinations

Ear Wax Removal

Men’s Health Clinic

Women’s Health Clinic

Weight Management

Period Delay

Covid Vaccination

Flu Vaccinations

Assessment for Period Delay

Period Delay

1 About Your Health

Question 1:Do you have any known allergies?

Yes

Question 2:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Question 3:Are you currently taking any medications?

Yes

Question 4:Have you had any surgeries in the past year?

Yes

Question 5:Do you smoke?

Yes

Question 6:Do you consume alcohol?

Yes

Question 7:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Question 8:How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Question 1:What is the average length of your menstrual cycle (in days)?

Question 2:How regular is your menstrual cycle? (e.g., very regular, somewhat regular, irregular)

Question 3:When is your next expected period?

Question 4:Why are you seeking to delay your period? (e.g., upcoming event, travel, personal preference)

Question 5:Are you currently experiencing any menstrual symptoms or other related symptoms? (e.g., cramps, bloating, mood swings)

Question 6:How severe are your symptoms on a scale of 1 to 10 (1 being mild and 10 being severe)?

Question 7:Have your symptoms interfered with your daily activities or quality of life?

Yes

Question 8:Have you been prescribed medication for period delay before?

Yes

Question 9:Are you currently taking any medication for period delay?

Yes

Question 10:Have you experienced any side effects from your current or past period delay medications?

Yes

Question 11:Have you tried any non-medication methods to manage your menstrual cycle? (e.g., lifestyle changes, dietary adjustments, stress management)

Yes

Question 12:Have you used over-the-counter treatments for menstrual management?

Yes

3 The Agreement and Consent

Question 1:Understanding of Risks

Question 2:Medical Guidance

Question 3:Consent to Share Information

Question 4:Confirmation

Assessment Progress

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