Q No.QuestionAnswer1I understand that acid reflux treatment supplied through this service can only be used for the short-treatment of gastroesophageal reflux disease (GORD) also known as heartburn/acid indigestion for a maximum of 28 days. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No2I understand that if I experience no relief after 14 days or my symptoms persist after 28 days of treatment I must contact my GP for further diagnosis/treatment. You must answer this question.You must answer this question.Please write your explanation in the box below Yes No3Do you have an allergy (hypersensitivity) to medicines containing protein pump inhibitiors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No4Are 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.Please write your explanation in the box below Yes No5Are you lactose intolerant? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No6Are you taking a medicine containing nelfinavir (used for HIV infection)? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No7Are you aware may this medication may cause dizziness or visual disturbance and must not drive or operate machinery if affected? You must answer this question.You must answer this question.Please write your explanation in the box below Yes No8Do you suffer from any of the following? • Unexplained weight loss • Difficulty swallowing • Liver or kidney disease • Severe or persistent diarrhoea • Black stools (blood stained faeces) • Vomiting food or blood • Sugar intolerance • History of gastric ulcers or surgery • Persistent loss of appetite • Low magnesium in the blood (hydromagnesaemia) • Cancer • Osteoporosis You must answer this question.You must answer this question.Please write your explanation in the box below Yes No9Are you taking any of the following medications? • Ketoconazole, itraconazole, posaconazole or voriconazole (used to treat infections caused by a fungus) • Digoxin (used to treat heart problems) • Diazepam (used to treat anxiety, relax muscles or in epilepsy) • Phenytoin (used in epilepsy) • Medicines that are used to thin your blood, such as warfarin or other vitamin K blockers • Rifampicin (used to treat tuberculosis) • Atazanavir (used to treat HIV infection) • Tacrolimus (in cases of organ transplantation) • St John’s wort (Hypericum perforatum) (used to treat mild depression) • Cilostazol (used to treat intermittent claudication) • Saquinavir (used to treat HIV infection) • Clopidogrel (used to prevent blood clots (thrombi) • Vitamin B12, cyanocobalamin, hydroxocobalamin • Erlotinib • Clarithromycin • Methotrexate You must answer this question.You must answer this question.Please write your explanation in the box below Yes No10I understand that I must stop taking the acid reflux treatment and contact my GP or other urgent healthcare provider if I experience any of the following conditions. • You lose a lot of weight for no reason and have difficulty swallowing • You get stomach pain or indigestion • You begin to vomit food or blood • You pass black stools (blood-stained faeces) • You experience severe or persistent diarrhoea • You have severe liver problems • You develop a persistent cough You must answer this question.You must answer this question.Please write your explanation in the box below Yes No11Do 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.Please write your explanation in the box below Yes No12What 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
