Flu Antiviral Assessment | Pharma Aesthetics

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Flu Antiviral Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Flu Antiviral 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

Have you experienced a sudden onset of fever or feeling feverish in the last 48 hours?*

Yes

No

Please provide more information below.*

Are you suffering from a cough or sore throat that appeared recently?*

Yes

No

Please provide more information below.*

Do you have muscle or body aches that are unexplained by other conditions or physical exertion?*

Yes

No

Please provide more information below.*

Are you experiencing severe fatigue or weakness that has suddenly developed?*

Yes

No

Please provide more information below.*

Have you noticed any respiratory symptoms such as difficulty breathing or shortness of breath?*

Yes

No

Please provide more information below.*

Health

Are you allergic to any components of flu antiviral medications, such as oseltamivir, zanamivir, peramivir, or baloxavir?*

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 any chronic medical conditions, such as asthma, diabetes, or heart disease, that could make flu more severe for you?*

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 a possibility you could be pregnant, as this may influence the choice of antiviral medication?*

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 currently taking any other medications, including over-the-counter drugs or supplements, that could interact with flu antivirals?*

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 vaccinated against the flu this season?*

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 I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions are designed to ensure the safe and effective prescription of flu antivirals, tailored to the patient's specific symptoms and health profile.

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.

Phone

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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