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Alternatives to the pill
General Health
Asthma
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Asthma
Are you registered with a GP practice in the UK?
Yes
No
Why are you not registered with a GP practice?
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:
Do you suffer from asthma or COPD?
Yes, asthma
Yes, COPD
Yes, both of these
Are you currently using a reliever inhaler? (blue inhaler/Salbutamol/Ventolin)
Yes
Which reliever inhaler are you using?
How many times a week are you using your reliever inhaler?
Rarely/never
Less than 3 times per week
Three times or more per week
Can you provide more information about why you are using your reliever inhaler three times or more per week?
How often are you woken up at night by your condition?
Never/rarely
One or more nights per week
How many days a week do you have symptoms (eg cough, wheeze, shortness of breath, chest tightness)?
Never/rarely
Less than 3 days a week
3 or more days per week
Have you been to hospital because of your condition in the last 12 months?
Yes
No
When were you last in hospital because of your asthma?
Has a doctor or nurse checked your asthma in the last 12 months?
Yes
No
Are you aware that you should attend an annual review of your condition with your GP every 12 months?
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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