Have you seen your GP about your condition?

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

Is your GP aware that you intend to take this medication to help with your pain and will you inform your GP that we have issued you with this medication?

Have you been prescribed this before?

Do you intend to take this to help with Neuropathic Pain?

Have you recently had any new or worsening pain?

Have you already tried simple over the counter pain killers for your pain?

Do you currently have any type of infection?

Have you ever had an addiction to medicines/drugs?

Are you aware this medication is potentially addictive with the risk of causing both physical and psychological dependence with regular use?

Do you intend to take this medication with alcohol in your system?

Please be aware that this medication can cause drowsiness which may impact on your ability to drive safely. We advise not to drive if you experience any symptoms or signs (such as experiencing sleepiness, poor coordination, impaired or slowed thinking, dizziness, or visual problems) suggesting that your driving may be impaired. Please confirm you understand and agree with this advice.

Have you been diagnosed with any of the following? 

• Kidney, Liver, or Heart problems
• Breathing problems even if well controlled including Asthma
• Diabetes
• Mental Health Problems (eg depression, anxiety, suicidal thoughts)
• Encephalopathy
• Any serious medical conditions which may necessitate immediate hospital review

Are you taking any of the following medications?  

• Antidepressant (used to treat depression and anxiety)
• Antiepileptic
• Anti-histamines e.g. Alimemazine, Hydroxyzine, Ketotifen, Promethazine, Chlorphenamine or Cinnarizine
• Antipsychotic medicines (used to treat mental illness e.g. Chlorpromazine and Risperidone).
• Barbiturates and benzodiazepines (medicines to calm you down or to help you sleep e.g. Phenobarbital, Diazepam, Alprazolam, Zopiclone, Zolpidem).
• Chemotherapy or related cancer drugs
• Clonidine, Moxonidine (Used to treat high BP)
• Cyclizine (to prevent sickness)
• Gabapentin 
• Guanfacine
• HIV medications
• Melatonin
• Methadone or Lofexidine
• Methocarbamol or Baclofen (types of muscle relaxant)
• Opiate painkillers (such as Morphine, Codeine, Tramadol, Buprenorphine or Fentanyl).
• Pizotifen (used for migraines)

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.