Consultation - Chemist 69

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:What is your date of birth?

Question 2:What is your gender?

Female

Male

Question 3:Do you have any known allergies?

Question 4:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

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

Question 5:Are you currently taking any medications?

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

Question 6:Have you had any surgeries in the past year?

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

Question 7:Do you smoke?

Question 8:Do you consume alcohol?

If yes, how much a day/weekly?

Question 9:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Question 10:How often do you exercise? (e.g., 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

Yes

Question 2:Medical Guidance

Yes

Question 3:Consent to Share Information

Yes

Question 4:Confirmation

Yes

Acid Reflux

Acne

Anxiety

Asthma

Contraception

Eczema

Erectile Dysfunction

Hair Loss

HRT

Malaria Prevention

Period Delay

Premature Ejaculation

TEST CONDITION

Weight Loss

Travel Clinic

Assessment for Period Delay

Period Delay

1 About Your Health

Question 1:What is your date of birth?

Question 2:What is your gender?

Question 3:Do you have any known allergies?

Yes

Question 4:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Question 5:Are you currently taking any medications?

Yes

Question 6:Have you had any surgeries in the past year?

Yes

Question 7:Do you smoke?

Yes

Question 8:Do you consume alcohol?

Yes

Question 9:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

Yes

Question 10:How often do you exercise? (e.g., daily, weekly, rarely, never)

Yes

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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