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.
Are you currently:
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.
Do you currently have or have you had any medical problems or surgeries/operations, for example:
Please provide more details
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you have any allergies to medications or any other substances?
Please list everything you are allergic to and what symptoms you experience.
Do you take or use any recreational drugs?
Please list everything you use. This information will not be shared with anyone apart from our prescribers.
What is your blood pressure?
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Do you currently smoke?
Please provide us with more information as to why you are requesting this treatment
When did you give up smoking?
How many cigarettes do you smoke on a daily basis?
How soon after waking do you have your first cigarette?
How long have you been smoking?
Are you currently using any medicines to help you stop smoking?
Please provide the name and dose of all the medications you are using and whether or not you have experienced any side effects
Have you previously used any other methods to try and stop smoking?
Why do you think this was not successful?
I am NOT pregnant, breastfeeding or planning to conceive.
Have you ever had any medical conditions or surgery not previously mentioned in this form?
Please provide details
I agree to stop using this medicine and contact my GP immediately if I notice that you are becoming agitated, depressed or having suicidal thought.
Have you ever been diagnosed with any of the following?
Please detail all that applies from the list above.
Are you currently using any medication for depression, anxiety or insomnia?
For example: Sertraline, Fluoxetine, Escitalopram, Venlafaxine or Citalopram
Please provide further information
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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