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Disclaimer - IBS Colofac Consulation Form

Your complete and honest disclosure will enable our healthcare professionals to make informed decisions and provide you with the best possible care. Please provide accurate and detailed information when needed in the consultation questionnaire below.

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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

If Yes Give Details

If Yes Give Details

If Yes Give Details


Have you been diagnosed with Irritable Bowel Syndrome (IBS) by a healthcare practitioner?
Are you pregnant or breast feeding?
What symptoms do you experience? Please select all that apply:
Do your symptoms relieve by passing a stool?

If Yes Give Details

How long have you had IBS symptoms?
Are you currently taking or have taken in the past any medications for IBS?

If Yes Give Details

If Yes Give Details

Do you have any of the following medical conditions? Please select all that apply:

If Yes Give Details

If Yes Give Details

If Yes Give Details

Please confirm the below; I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform
Would you like us to notify your GP of the medication you choose to order today?
Product
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