Consultation - RX Direct

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.

Understanding of Risks

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

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.

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.

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.

Acid Reflux

Contraceptives

Erectile Dysfunction

Hair Loss

Malaria Prevention

Period Delay

Premature Ejaculation

Weight Loss

Assessment for Period Delay

Period Delay

1 About Your Health

What is your date of birth?

What is your gender?

Do you have any known allergies?

Yes

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

Yes

Are you currently taking any medications?

Yes

Have you had any surgeries in the past year?

Yes

Do you smoke?

Yes

Do you consume alcohol?

Yes

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

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

2 About Your Condition

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

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

When is your next expected period?

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

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

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

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

Yes

Have you been prescribed medication for period delay before?

Yes

Are you currently taking any medication for period delay?

Yes

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

Yes

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

Yes

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

Yes

3 The Agreement and Consent

Understanding of Risks

Medical Guidance

Consent to Share Information

Confirmation

Assessment Progress

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