Genital Herpes Assessment | Pharma Aesthetics

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Genital Herpes Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Genital Herpes 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 noticed any blisters or sores on or around your genital area, buttocks, or thighs?*

Yes

No

Please provide more information below.*

Do you experience itching or pain around your genital area?*

Yes

No

Please provide more information below.*

Have you observed any unusual vaginal or penile discharge recently?*

Yes

No

Please provide more information below.*

Are you experiencing painful urination?*

Yes

No

Please provide more information below.*

Have you had any flu-like symptoms, such as fever, headache, or body aches, during an outbreak?*

Yes

No

Please provide more information below.*

Health

Are you allergic to any antiviral medications, such as acyclovir, valacyclovir, or famciclovir?*

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 pregnant, planning to become pregnant, or breastfeeding?*

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 kidney problems or a history of kidney disease?*

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 taking any other medications, including over-the-counter drugs or herbal supplements, that could interact with genital herpes treatment?*

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 HIV or any other condition that affects your immune system?*

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 gather essential information for the safe and effective prescription of treatments for genital herpes, considering both the patient's symptoms and their overall health condition.

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.

Email

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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