Acid Reflux Questionnaire

Select 'Yes' if you give permission to share this information with or seek more information from your GP, we will hold your order until GP approval has been given. Not providing consent may limit the services provided by the prescriber.

Yes

1. Have you seen your GP about your condition?

Yes

2. Are you pregnant, breast feeding or intending to become pregnant?

Yes

3. Have you taken this medication before and tolerated it well?

Yes

4. Have you been diagnosed with Dyspepsia (indigestion)?

Yes

5. The following symptoms may indicate that you require further investigations to look into the cause of your symptoms and we therefore recommend that you discuss the matter with your GP. Do you suffer with any of the following? • Persistently worsening indigestion • Associated vomiting or ever vomited blood • Unexplained weight loss • Difficulty swallowing • Black stools • Persistent diarrhoea • Low sodium or Magnesium in your blood.

Yes

6. Please provide a history of your symptoms (how and when it started, and how it impacts your day-to-day routine).

Please enter a minimum of 5 words

Number of words entered: 0

7. Please list any allergies or medical conditions you have.

8. Please list any medication you are taking, including over the counter or herbal remedies.

9. Have you been diagnosed with any of the following? • Kidney or Liver problems • Gastric Ulcers • Cutaneous Lupus • Osteoporosis

Yes

Are you taking any of the following medications? • Antifungals e.g. Ketoconazole • HIV medication • Chemotherapy or related cancer drugs • Cilostazol • Citalopram • Chemotherapy or related cancer drugs • Clopidogrel • Dipyridamole • Escitalopram • HIV medication • Methotrexate

Yes

Standard T&C • I will read the patient information leaflet supplied with my medication • I will contact my GP or MyMedsUK if I experience any side effects • The treatment is for my use only • I have answered the assessment questions truthfully and accurately • I agree to the Terms and Conditions and I confirm that I am over 18 years old • I am aware that I may be contacted to give further information via phone or email and if I am not contactable this will lead to a delay in receipt of my prescription.

Yes

Why are you looking to use our service instead of your own GP or other healthcare provider?

Please enter a minimum of 5 words

Number of words entered: 0

Please provide details of the last time you discussed this medical problem with your GP/Consultant. (Please include details such as date seen, their thoughts about your ongoing use of this medication and the next proposed review date.)

Please enter a minimum of 5 words

Number of words entered: 0

Based on the answers you have provided, we advise you to visit your GP for a personal consultation. Please make an appointment with your GP at your earliest convenience.
Alternatively, please revisit the questionnaire, if you think you made an error in your answers.

Great, you've be provisionally approved for this treatment. Click 'Continue' to complete your order.

We're nearly done.

Your Chosen Treatment:

Acid Reflux

Step 1: Questionnaire

6. Please provide a history of your symptoms (how and when it started, and how it impacts your day-to-day routine).

7. Please list any allergies or medical conditions you have.

8. Please list any medication you are taking, including over the counter or herbal remedies.

Why are you looking to use our service instead of your own GP or other healthcare provider?

Please provide details of the last time you discussed this medical problem with your GP/Consultant. (Please include details such as date seen, their thoughts about your ongoing use of this medication and the next proposed review date.)

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