Disclaimer - Acid Reflux Consultation Form

This questionnaire forms the basis of your consultation today. We require you to be truthful and transparent with your answers including any current medication you are on, your medical history and any other information our prescribers should be made aware of. This allows our prescribers to provide you with the best advice and choice of medication suited to your need. Please read all the medical information before choosing your preferred treatment.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?

What is your Date of Birth?

Day

Month

Year

Have you been diagnosed with any medical conditions? Yes | No

If Yes Give Details

Have you ever been diagnosed with a mental health illness? Yes | No

If Yes Give Details

Do you suffer from any allergies? Yes | No

If Yes Give Details

Have you ever been diagnosed with liver or kidney disease? Yes | No

If Yes Give Details

Do you experience symptoms of acid reflux at least twice a week? Symptoms include: Burning in the throat Fluid that tastes acidic in the back of the throat Heartburn - a burning feeling in the chest after eating Chest pain after bending over, Yes | No

If Yes Give Details

Are you experiencing any of the following? Difficulty swallowing Unintentional weight loss Abdominal swelling Persistent vomiting Blood in your vomit Severe or persistent diarrhoea Blood in your stools Black, tarry stools Have an iron deficien Yes | No

If Yes Give Details

Are you pregnant or breast-feeding or intending either whilst taking treatment? Yes | No

If Yes Give Details

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? Yes | No

If Yes Give Details

Do you have any known allergies? Yes | No

If Yes Give Details

Are you allergic to proton pump inhibitors? (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)? Yes | No

If Yes Give Details

Are you pregnant, breastfeeding or possibly pregnant? Yes | No

If Yes Give Details

Do you suffer from any of the following: Osteoporosis Liver problems Gastric cancer Hypomagnesaemia (low magnesium in the blood) Yes | No

If Yes Give Details

Whilst taking proton pump inhibitors, have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure? Yes | No

If Yes Give Details

Are you taking any of the following medications? NSAID anti-inflammatory medication (e.g. ibuprofen) Antifungals-Ketoconazole, itraconazole, posaconazole or voriconazole Digoxin Diazepam Ulipristal Phenytoin or Fosphenytoin Blood thinners- Yes | No

If Yes Give Details

Please specify any other medication

Please provide any further information that you think will help our prescriber when reviewing this request for medication. (optional)

Healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable. Do you understand this?

Acid reflux treatment from this service to treat acid reflux can only be used for a maximum of 28 days. Do you understand this?

If you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment. Do you understand this?

Would you like us to inform your GP?

To continue, please provide your GP's surgery address below.

Product

Omeprazole Capsules£1.99