Omeprazole 20mg X 28 Capsules

Omeprazole 20mg X 28 Capsules

From £10.25

Dyspepsia Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your dyspepsia consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

I understand if all acid symptoms do not settle within 5 days of treatment I need to see my regular GP. This is because Famotidine 20mg twice daily or Omeprazole 20mg daily for 5 days should settle all symptoms for at least a few days*
I understand I require a review by my regular GP if the following apply:*
• Symptoms are not controlled by taking treatment two to three times weekly. • Symptoms are changing or worsening.
Do any of the following apply to you?*
• Jaundice • Anaemia • Unintentional Weight Loss • Difficulty or pain on swallowing • Previous gastric ulcer or surgery • Vomiting, particularly if there is blood in the vomit • Age 45 or over with new onset of symptoms • Age 45 or over where symptoms are worsening

Health

Are you taking any prescription-only medicines, alternative medicines or recreational drugs?*
Do you have any known allergies to any medicine or substances?*
Do you have any other health problems or conditions that you think we should know about? (e.g. Myasthenia Gravis, any enzyme deficiencies or recent major operations etc.)*
Are you currently pregnant, planning to become pregnant or breastfeeding?*

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Your Details

Name*
Date of Birth*
Your Home Address*

Please Confirm

Personal*
If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
This field is for validation purposes and should be left unchanged.
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