1
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?

NoYes

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?

NoYes

Sorry we can't offer you this treatment, please contact your GP.

Have you been diagnosed with any medical conditions?

NoYes

Please provide more detail.

Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.

NoYes

Please provide more detail.

Do you suffer from any allergies?

NoYes

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?

NoYes

Please provide more detail.

2
Medical Questions

Have you been diagnosed with IBS by your doctor?

NoYes

Are you suffering from stomach cramps?

NoYes

Are you experiencing constipation?

NoYes

Are you experiencing diarrhoea?

NoYes

Are you experiencing excessive wind?

NoYes

Are you suffering from bloating?

NoYes

Are your symptoms relieved by passing stool?

NoYes

Do you experience altered stool passage? (straining, urgency or unable to pass a full stool)

NoYes

Do you experience bloating or abdominal distension/hardness?

NoYes

Are your symptoms often made worse by eating?

NoYes

Do you experience the passing of mucus when passing a stool?

NoYes

How long have you suffered from these symptoms?

Have you experienced blood passing in your stools?

NoYes

Please provide more information

Have you unintentionally lost weight or have your regular IBS symptoms changed recently?

NoYes

Please provide more information

Are you buying more than one of this treatment?

NoYes

Please tell us why

Is there anything that noticably causes your symptoms or makes them worse?

NoYes

Please provide more information

3
Consent

Would you like us to notify your GP of the treatment you chose to order today?

NoYes

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:

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 are aware you will be subject to a soft check to validate your identity via Experian
You will read the Patient Information Leaflet supplied with your medication
You agree to Cloud Pharmacy terms and conditions and privacy policy.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully
You will inform your GP of this purchase if appropriate

NoYes

Sorry we can't offer you this treatment, please contact your GP.

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.

Assessment

Trust Pilot

Medical Questions

2
Medical Questions

3
Consent

Confirm Mebeverine 135mg Tablets treatment selection

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Assessment

Trust Pilot

Medical Questions

2Medical Questions

3Consent

Confirm Mebeverine 135mg Tablets treatment selection

2
Medical Questions

3
Consent