Acid Reflux / Heartburn Assessment | Pharma Aesthetics

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Acid Reflux / Heartburn Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Acid Reflux / Heartburn Treatment 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

Do you frequently experience a burning sensation in your chest, especially after eating or at night?*

Yes

No

Please provide more information below.*

Have you noticed a sour or bitter taste in your mouth, particularly following meals or when bending over or lying down?*

Yes

No

Please provide more information below.*

Do you often find yourself coughing or experiencing a sore throat without any signs of a cold or flu?*

Yes

No

Please provide more information below.*

Have you had difficulty swallowing or felt as though food is stuck in your throat or chest recently?*

Yes

No

Please provide more information below.*

Are your symptoms of heartburn or acid reflux occurring more than twice a week?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medication, whether prescription or over-the-counter, that could potentially worsen acid reflux symptoms (e.g., anti-inflammatories, certain blood pressure medications)?*

Yes

No

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

Have you been diagnosed with any gastrointestinal conditions, such as gastroesophageal reflux disease (GERD), hiatal hernia, or peptic ulcer?*

Yes

No

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

Are you pregnant or is there any chance you might be pregnant, considering some treatments may not be suitable during pregnancy?*

Yes

No

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

Do you have a history of liver or kidney disease, which could affect the type of medication prescribed for acid reflux?*

Yes

No

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

Have you previously tried any over-the-counter antacids or acid reducers, and did you experience any adverse reactions or lack of improvement in your symptoms?*

Yes

No

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

Acknowledgements

Please Confirm

I understand if my Acid Reflux / Heartburn gets worse, I must see a GP.

Consent

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

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

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.

Comments

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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