Period Pain - WePrescribe

Period Pain Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

Are you currently suffering with painful cramping in the lower abdomen (stomach) area?

Are you currently experiencing any of the symptoms listed below?

- Similiar symptoms when you are not on your period - pain in the genital area during sexual intercourse - Consistent bleeding when you are not on your period - Any vaginal discharge

Have you ever suffered with any internal bleeding within the stomach area, caused by medication or anything else?

Do you or have you ever suffered with any conditions relating to your heart?

If so, please provide more information

Please provide more details

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

If so, please provide more information

Please provide more details

Do you currently take any medication? This includes herbal remedies and over the counter medication.

If so, please provide more information

Please provide more details

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

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

If so, please provide more information

Please provide more details

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

I have read and understood the Terms and Conditions.

Please see our terms and conditions here

Period Pain Consultation

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