Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
What symptoms is this medicine being used to treat?
Usually oral thrush is on the surface of the tongue and insides of the cheeks.
How long have you suffered from these symptoms?
Have you seen your doctor or practitioner on this occasion or in the past?
What comments did they make?
Do you have any of the following symptoms:
• Oral thrush that's been present for more than 3 weeks • Mouth ulcers • A problem with your immune system • Difficulty or pain on swallowing • Pain behind the breastbone
Please specify what symptoms you suffer from and for how long
Do you have symptoms of Thrush anywhere else on the body?
For example: the vagina or penis
Please provide more information
Have you tried any oral thrush treatments for this outbreak or past outbreaks?
Which treatments have you tried and were they effective?
Do you know the cause of your symptoms?
For example: recent antibiotic course, use of steroids (brown inhaler), diabetes or denture use
Please specify the cause of the symptoms
Do you suffer from any of the following:
Do you currently take any of the following medicines:
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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