Q No.QuestionAnswer1Are you pregnant or breastfeeding or trying to become pregnant?Bottom of Form You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2Do 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 No3Do you know what is causing your pain? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Have you used the treatment you are requesting before and did it help with the pain? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No5Have you seen your GP about your pain? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6Are you currently seeing, or have you recently seen, a hospital specialist? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Do any of the following symptoms accompany your pain? Redness of the painful area Swelling of the painful area Bruising Weakness Broken skin Area is painful to touch Nausea You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8Are you currently taking any medication to relieve your pain? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Do you agree to see your GP if: Your pain doesn’t improve with treatment Your pain worsens with or without treatment You’re in severe pain Your pain spreads to new areas Your pain impacts your quality of life 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 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 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
