| 1 | Are you female?
You must answer this question. You must answer this question. | |
| 2 | Do you have an allergy to Aspirin, Mefenamic acid or any other anti-inflammatory medication?
You must answer this question. You must answer this question. | |
| 3 | Are you taking any medication to treat diabetes?
You must answer this question. You must answer this question. | |
| 4 | Do you have high blood pressure (above 150/90)?
If you are unsure you can get this measured at your local pharmacy or GP practice.
You must answer this question. You must answer this question. | |
| 5 | Do you suffer from any of the following?
• High temperature
• Vaginal discharge
• Irregular periods
• Vaginal bleeding after sexual intercourse
• Sudden severe abdominal pain
• Pain in between periods
You must answer this question. You must answer this question. | |
| 6 | Do you suffer from any of the following?
• Asthma
• COPD (Chronic obstructive pulmonary disorder)
• Liver disease
• Kidney disease
• Mild to severe heart failure
• Galactose intolerance
• Blood disorder
• Epilepsy
• Inflammatory bowel disease
• Had major surgery
You must answer this question. You must answer this question. | |
| 7 | Are you taking any of the following medication?
• Anti-coagulants (e.g warfarin, heparin)
• Diuretics
• Lithium (for depression)
• Medicines for treatment of heart conditions (e.g Digoxin)
• Any other NSAID (e.g aspirin, ibuprofen, diclofenac)
• SSRIs (e.g fluoxetine, sertraline, for depression)
You must answer this question. You must answer this question. | |
| 8 | Do you smoke or drink alcohol?
You must answer this question. You must answer this question. | |
| 9 | Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication?
You must answer this question. You must answer this question. | |
| 10 | Do you agree to the following?
• You will seek medical attention if you experience any unusual side effects
• The treatment is solely for your own use
• You will read the patient information leaflet supplied with your medication
• You will not smoke or drink alcohol while taking this course of medication
You must answer this question. You must answer this question. | |
| 11 | What is the name of your GP surgery and do you consent to us contacting them about your treatment?
You must answer this question. You must answer this question. | |
