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Women's Health
Period Delay
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Asthma
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Acid Reflux
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Acid Reflux
Do you believe you have the capacity to make decisions about your own healthcare?
Yes
No
Have you been diagnosed with any medical conditions?
Yes
No
Please provide more information, including diagnosis, symptoms and treatment.
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Yes
No
Which medication, what strength and how often are you taking it?
Do you suffer from any allergies?
Yes
No
What allergies do you have and what are the symptoms you experience from an allergic reaction?
Is there anything else you would like to include for the prescriber?
Yes
No
Please provide further information:
Have you been diagnosed with acid reflux?
Yes
No
Who made the diagnosis and when (month/year)?
Are you currently taking any acid reflux medication?
Yes
No
Which medication are you taking (including dose)?
Are you allergic to medicines containing proton pump inhibitors?
Yes
No
Are you experiencing symptoms of acid reflux at least twice a week?
Yes
No
Please provide further details of the acid reflux symptoms you are experiencing
Have you ever had a stool sample or breath test for your acid reflux symptoms?
Yes
No
Was the test positive for helicobacter pylori infection?
Yes
No
I'm not sure
Was this treated with antibiotics?
Yes
no
Do you experience food sticking in your throat/food pipe after swallowing?
Yes
No
Do you experience symptoms of persistent vomiting?
Yes
No
Do you cough up blood?
Yes
No
Have you ever noticed blood in your stool?
Yes
No
Are you more than 55 years of age?
Yes
No
Is this the first time you are experiencing significant acid reflux symptoms?
Yes
No
Have you ever suffered from heart, liver or kidney problems?
Yes
No
Are you breastfeeding, pregnant or planning to become pregnant?
Yes
No
Have you been diagnosed with hypomagnesaemia, osteoporosis or gastric cancer?
Yes
No
Are you using this medication to help protect the stomach (gastroduodenal protection)?
Yes
No
Do you agree to the following?
You agree to our terms and conditions, privacy policy and acceptable use policy
You will read the Patient Information Leaflet supplied with your medication
The treatment is solely for your own use
You are aware you will be subject to a soft check to validate your identity via Yoti
You have answered all the above questions accurately and truthfully
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
You will inform your GP of this purchase if appropriate
Yes
No
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