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Jet Lag Assessment

Jet Lag Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Jet Lag 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 difficulty falling asleep at night or waking up earlier than usual since travelling across time zones?*

Yes

No

Please provide more information below.*

Do you feel unusually tired and fatigued during the day despite resting?*

Yes

No

Please provide more information below.*

Are you experiencing any problems with concentration or memory since your recent travel?*

Yes

No

Please provide more information below.*

Have you noticed any changes in your appetite or gastrointestinal disturbances, such as constipation or diarrhoea, following your trip?*

Yes

No

Please provide more information below.*

Do you feel unusually irritable or experiencing mood swings post-travel?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medication that could affect your sleep pattern or interact with potential jet lag treatments?*

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 pre-existing sleep disorders, such as insomnia or sleep apnea, that could be exacerbated by jet lag?*

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 suffer from any chronic illnesses that might influence how you respond to jet lag treatments, such as diabetes or heart 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 pregnant, planning to become pregnant, or breastfeeding, which might limit the treatment options available to 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):*

Have you used any remedies or medications for jet lag in the past, and did you experience any side effects or find them ineffective?*

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 aim to ensure a comprehensive evaluation of the patient's symptoms and health status, allowing for the safe and effective prescription of treatments for jet lag.

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.

Name

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

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