Q No.QuestionAnswer1Are you female? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Do you have an allergy to Aspirin, Mefenamic acid or any other anti-inflammatory medication? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Are you taking any medication to treat diabetes? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Do 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.Please write your explanation in the box below Yes No5Do 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.Please write your explanation in the box below Yes No6Do 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.Please write your explanation in the box below Yes No7Are 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.Please write your explanation in the box below Yes No8Do you smoke or drink alcohol? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are 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.Please write your explanation in the box below Yes No10Do 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.Please write your explanation in the box below Yes No11What 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.Please write your explanation in the box below Gender * Male Female Other First Name * Last Name * Date of birth * Contact Number * Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * Check to add patient. Patient Gender * Male Female Other Patient First Name * Patient Last Name * Patient Date of birth * Patient Contact Number * Patient Door number * Search address by postcode * Note:- Please don't repeat door number Postal code * I confirm that I am over 18 and I agree to the Terms and Conditions.Term and Conditions required!Please fill all required fields
