| 1 | I 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. | |
| 2 | I 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. | |
| 3 | Are 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. | |
| 4 | Are 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. | |
| 5 | I 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. | |
| 6 | Are you allergic to Champix (Varenicline)?
You must answer this question. You must answer this question. | |
| 7 | 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. | |
| 8 | Do 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. | |
| 9 | Are 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. | |
| 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 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. | |
