What is your Date of Birth?
Have you been diagnosed with any medical conditions? Yes | No
Have you ever been diagnosed with a mental health illness? Yes | No
Do you suffer from any allergies?
Yes | No
Have you ever been diagnosed with liver or kidney disease?
Yes | No
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
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
Are you pregnant or breast-feeding or intending either whilst taking treatment?
Yes | No
Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?
Yes | No
Do you have any known allergies?
Yes | No
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, lying down
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 deficiency Yes | No
Are you allergic to proton pump inhibitors? (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?
Yes | No
Are you pregnant, breastfeeding or possibly pregnant?
Yes | No
Do you suffer from any of the following:
Osteoporosis
Liver problems
Gastric cancer
Hypomagnesaemia (low magnesium in the blood)
Yes | No
Whilst taking proton pump inhibitors, have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure?
Yes | No
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
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.
