| 1 | I 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. | |
| 2 | I 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. | |
| 3 | Do 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. | |
| 4 | Are 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. | |
| 5 | Are you lactose intolerant?
You must answer this question. You must answer this question. | |
| 6 | Are you taking a medicine containing nelfinavir (used for HIV infection)?
You must answer this question. You must answer this question. | |
| 7 | Are 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. | |
| 8 | Do 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. | |
| 9 | Are 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. | |
| 10 | I 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. | |
| 11 | Do 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. | |
| 12 | What 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. | |
