1. Have you seen your GP about your condition?

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

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

5. Have you been prescribed this before?

6. 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?

7. Have you recently had any new or worsening pain since seeing your doctor?

11. Have you ever had an addiction to medicines containing codeine or morphine?

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

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

16. 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.

17. Have you been diagnosed with any of the following? • Kidney, Liver, Pancreas or Heart problems • Low Blood Pressure (<90/60) • Chronic constipation, a Stoma or a Blocked bowel • Breathing problems even if well controlled including Asthma • Prostate problems or problems passing urine • Stomach or intestinal problems (such as Crohn’s disease or Ulcerative colitis) • Underactive thyroid • Systemic Lupus Erythematosus (SLE) (Lupus) or Myasthenia Gravis. • Recent head injury • Epilepsy or fits • Any serious medical conditions which may necessitate immediate hospital review

20. 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). • Antifungal e.g. Terbinafine • Barbiturates and benzodiazepines (medicines to calm you down or to help you sleep e.g. Phenobarbital, Diazepam, Alprazolam, Zopiclone, Zolpidem). • Benperidol • Chemotherapy or related cancer drugs • Clomethiazole • Rifampicin (types of antibiotic) • Clonidine or Moxonidine (Used to treat high BP) • Cyclizine (to prevent sickness) • Gabapentin or Pregabalin • Guanfacine • HIV medications • Melatonin • Methadone or Lofexidine • Methocarbamol or Baclofen (types of muscle relaxant) • Other Opiate painkillers (such as Morphine, Tramadol, Buprenorphine or Fentanyl). • Naltrexone (used in the treatment of drug dependence). • Pizotifen (used for migraines)

21. Are you in agreement to stop taking this medicine and seek immediate medical advice if you experience any of the following symptoms: Slow or shallow breathing. Confusion. Sleepiness. Small pupils. Feeling nauseous or being sick. Constipation. Lack of appetite.

22. Do you understand that: • The maximum dose is two tablets, four times daily, unless you are taking Dihydrocodeine in which case the maximum dose is one tablet, six times daily. • There should be a gap of at least 4 hours between doses. • Co-codamol, Solpadol, Zapain Co Dydramol Remedeine and Kapake should not be taken for more than 3 days consecutively. • You should not take Co-codamol, Solpadol, Zapain Co Dydramol Remedeine and Kapake tablets with other medicines containing paracetamol, codeine or dihydrocodeine.

23. Do you agree to speak to your doctor if any of the following occur: • Your pain does not improve with treatment. • Your pain is getting worse. • Your are in severe pain. • Your pain is spreading to other areas of the body. • Your pain is having a significant long-term impact on your quality of life.

24. 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