Disclaimer - Pain Consultation 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.

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?

Have you ever been diagnosed with a mental health illness?

Do you suffer from any allergies? Yes | No

If Yes Give Details

Do you take any medication? This can be prescribed medication or any other over the counter or herbal medicines? Yes | No

If Yes Give Details

What is the primary location and cause of your pain? (please give as much information as possible)

How long have you been experiencing this pain?

Please describe the nature of the pain e.g. sharp, dull, throbbing and any other symptoms you may have related to your pain.

Please describe the nature of the pain e.g. sharp, dull, throbbing and any other symptoms you may have related to your pain. (please provide as much information as possible)

On a scale of 1-10, how would you rate your pain? (10 being the highest level of pain)

Have you previously been prescribed pain relief medication for this condition?

Please provide more information including what medicines and strengths you have used

Have you used the medication before which you are requesting today?

Is there anything which makes the pain worse or less? (please provide as much information as possible)

Have you had your pain reviewed by your GP?

Please provide more information

Do you understand that pain relief medication should be used short term. If you require this medication long term, we would encourage you to see your GP for a review.

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

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 my own regular doctor of

Would you like us to notify your GP of the medication you choose to order today?

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

Product

Ibuprofen 400mg Tablets£6.99