Q No.QuestionAnswer1 Are you pregnant or breastfeeding or likely to become pregnant? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2 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 No3Have you been diagnosed with any of the following? epilepsy diabetes or impaired glucose tolerance significant liver or kidney disease (ask your doctor if not sure) autoimmune disease (body attacked by own immune system) You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4 Do you have any allergies? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5Are you taking any of the following medications? fluvoxamine (an antidepressant) psoralens (treatment for psoriasis) cimetidine (treatment for stomach acid and ulcers) quinolones (type of antibiotic) rifampicin (type of antibiotic) carbamazepine (anti-epileptic treatment) benzodiazepines (various sedatives and sleeping tablets) warfarin (anticoagulant – blood thinning) You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6 Do you have any medical conditions? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Are you aware melatonin can cause drowsiness? Melatonin may impair driving and operating machinery. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8 Do you take any recreational drugs? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are you aware that there are various things that you can do to reduce some of the effects of jet lag alongside taking medication? These include: Slowly adjusting your schedule to the new time zone before you fly Getting plenty of natural light in daylight hours when you land Staying hydrated Not sleeping during the daytime even if you’re tired Sleeping at night time in the new time zone Using eye masks and earplugs to help with restful sleep if you experience insomnia You must answer this question.You must answer this question.Please write your explanation in the box below Yes No10 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 prescribers 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 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
