Are you pregnant or breastfeeding?

Have you been diagnosed with reduced immunity from any cause?

For instance you have:

• Had a bone marrow transplant or low white blood cell count.
• Been diagnosed with a neurological abnormality or any condition leading to permanently low oxygen levels.

Note: most people who are troubled with cold sores have normal immune systems.

Do you have any problems with your liver or kidneys?

Includes conditions which could reduce kidney function – does not include occasional urinary infections. Kidney disease can be part of the ageing process and people over 65 should check with their GP.

Are you taking any of the following medication?

• Probenecid (used to treat gout).
• Cimetidine (used to treat stomach ulcers).
• Mycophenolate mofetil (used to stop your body rejecting transplanted organs).
• Ciclosporin (an immunosuppressant drug).
• Theophylline or aminophylline (used in asthma and other breathing problems).
• Zidovudine (used in HIV infection).

Do you have any of the following symptoms of cold sores?

• Tingling or itching around the mouth which may only affect a small area around your lips
• A small spot or blister filled with fluid. It may appear red and painfult to touch. The spot is usually found around the outside of your lips, but can sometimes be found nearer to the nose or cheeks
• Oozing or the small spot of blister that may form a crust

Are you aware aciclovir cream is not for internal use or for use in or around the eye?

Not for use in the vagina, mouth, or anus.

Are you aware you should seek medical advice if sores are getting worse or are not healing after 10 days?

Do you have any condition that causes you to have a weakened immune system, including HIV or AIDS?

Do you have any of these symptoms in addition to regular symptoms of cold sores?

• Mouth ulcers
• Pain, inflammation or discomfort in your gums
• Blisters or lesions around one or both eyes

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

What is the name of your GP surgery and do you consent to us contacting them about your treatment?