Dose the patient being treated have any of the following conditions?

• Have unusually high amounts of bleeding during menstruation.

• Very severe symptoms.

• These symptoms did not begin until mid 20's or later.

• Experiencing these symptoms at a time other than the beginning of menstruation.

• Pelvic Inflammatory Disease.

• Ovarian cysts.

• Infertility.

• Endometriosis.

• Abnormal menstrual cycles.

• Using an intrauterine device.

• Allergic to over the counter pain relievers including ibuprofen, naproxen, acetaminophen or aspirin.

• Currently take lithium, warfarin, or heparin.

• Any gastrointestinal diseases such as ulcerative colitis, irritable bowel syndrome, or peptic ulcer disease.

• Blood clotting conditions.


Yes

No



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