Q No.QuestionAnswer1 Are you pregnant or breastfeeding? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Have you been diagnosed with thrush before which has gone with simple treatment? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3 Do you have any problems with your liver or kidneys? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Have you had more than two thrush infections in the last six months? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5Are you allergic to the ingredients of the treatment you wish to use? Single dose oral tablets contain fluconazole Creams/pessaries containĀ clotrimazole / miconazoleĀ /Ā anti-fungal cream You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6Have you or your partner had exposure to sexually transmitted disease? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Do you have any of the following? MEN: Sores, blisters or ulcers on or around the penis Discharge (mucous like substance) leaking from the end of the penis WOMEN: Sores, blisters or ulcers in the vaginal area Irregular or unexplained vaginal bleeding You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8Are you taking the antihistamine terfenadine or the prescription medicine cisapride? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Have you been diagnosed with liver or kidney disease? Not including very minor illness that has completely resolved or occasional urinary infections. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No10Are you aware that there are other things you can do to ease your symptoms in addition to medication? Things you can do to ease and prevent thrush include: Avoiding scented products to wash your genitals and sticking to water and emollient Making sure the affected area is completely dry before putting on underwear Wearing cotton underwear instead of synthetic fabrics, as cotton is more breathable whereas synthetic fabrics encourage moisture Avoiding sex until your symptoms have cleared Taking showers instead of baths Avoiding douching your vagina (females) You must answer this question.You must answer this question.Please write your explanation in the box below Yes No11Do you suffer from any chronic disease likely to reduce your immunity? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No12Are you aware thrush symptoms should go within 10 days of starting treatment? Thrush symptoms should go within 10 days of starting treatment. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No13 Do you agree to the following? You will read the Patient Information Leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment The treatment is solely for your own use You are over the age of 18 and you have entered your own information for our identity verification checks You have answered all the above questions accurately and truthfully You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health You will inform your own GP of this purchase if appropriate You have read our privacy policy, cookie policy, patient agreement, data sharing agreement and Terms & Conditions. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No14What 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
