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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

Please ensure you are fully aware that you must see your regular GP should the acid symptoms not settle within 5 days of treatment.
Please Confirm by selecting yes above.

Please ensure you are fully aware that you must see your regular GP for a review if symptoms are not controlled by taking treatment two to three times weekly and/or symptoms are changing or worsening.
Please Confirm by selecting yes above.

Please provide more information below.*

Health

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Consent

Your Details

Phone

Please Confirm

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.

Product Name

Total

Phone

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Losec MUPS 40mg X 7

Dyspepsia Medical Questionnaire

Ordered Before?

Medical Questionnaire

Your Symptoms

Health

Consent

Your Details

Please Confirm

Description

Reviews

Losec MUPS 40mg X 7

Dyspepsia Medical Questionnaire

Ordered Before?

Medical Questionnaire

Your Symptoms

Health

Consent

Your Details

Please Confirm

Description

Reviews

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