Book Acid Reflux

Acid Reflux - Medical Assessment

If you have ordered this medication before, you can log in here to fill up the questionnaire automatically. Our pharmacists have a few quick and easy questions to help issue your FREE online prescription.

About You

Are you registered with a GP practice in the UK?

Yes No

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you?

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Yes No

Do you believe you have the capacity to make decisions about your own healthcare?

Yes No

Symptoms

Are you experiencing acid reflux at least twice a week? Symptoms include:

Heartburn - a burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours
Chest pain, especially after bending over, lying down or eating
Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat
Feeling of food "sticking" in the middle of the chest or throat

Yes No

Are you experiencing any of the following?:

difficulty swallowing
unintentional weight loss
abdominal swelling
persistent vomiting
severe/persistent diarrhoea
vomiting blood
blood in your stools or black, tarry stools
have iron deficiency anaemia
severe liver problems

Yes No

Health

Do you have an allergy (hypersensitivity) to medicines containing proton pump inhibitors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?

Yes No

Are you breast feeding or pregnant or possibly pregnant?

Yes No

Do you have any of the following conditions:

Osteoporosis
Liver problems
Gastric cancer
Hypomagnesaemia (low magnesium in the blood)

Yes No

Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor?

Yes No

Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Agreement

Do you understand that healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable?

Yes No

Do you 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?

Yes No

Do you understand that if you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment?

Yes No

Do you agree to the following?

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
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 are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

Yes No