Q No.QuestionAnswer1I am aware Champix (Varenicline) increases my chances of successfully giving up smoking but I will also need the willpower to succeed. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2I understand I should set a date to stop smoking between day 8 – 14 of the Champix (Varenicline) treatment course. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Are you aware that the dose of Champix (Varenicline) when commencing treatment is 0.5mg once a day for day 1-3, then 0.5mg twice a day for day 4-7 then 1mg once a day thereafter? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Are you aware Champix (Varenicline) may cause dizziness or drowsiness, if affected do not drive or operate machinery? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5I understand that I must stop taking Champix (Varenicline) and contact my GP or other urgent healthcare provider if I experience any of the following conditions. • New or worse heart or blood vessel (cardiovascular) problems • Seizures • Increased depression/anxiety, changes in behaviour, agitation, suicidal thoughts • Swelling of face mouth or neck You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6Are you allergic to Champix (Varenicline)? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Are 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 No8Do you suffer from any of the following? • Depression, anxiety or other psychiatric conditions • History of seizures/epilepsy • Kidney disease • Diabetes • Heart disease/stroke You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are you taking any of the following medications? • Anti-depression medication • Cimetidine for gastric problems • Theophylline, warfarin or insulin 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 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
