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Home / Online Doctor / Dyspepsia / Lansoprazole 30mg X 28 Capsules

Lansoprazole 30mg X 28 Capsules

From £12.25

Dyspepsia Medical Questionnaire

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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

I understand if all acid symptoms do not settle within 5 days of treatment I need to see my regular GP. This is because Famotidine 20mg twice daily or Omeprazole 20mg daily for 5 days should settle all symptoms for at least a few days*

Yes

No

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.

I understand I require a review by my regular GP if the following apply:*

• Symptoms are not controlled by taking treatment two to three times weekly. • Symptoms are changing or worsening.

Yes

No

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.

Do any of the following apply to you?*

• Jaundice • Anaemia • Unintentional Weight Loss • Difficulty or pain on swallowing • Previous gastric ulcer or surgery • Vomiting, particularly if there is blood in the vomit • Age 45 or over with new onset of symptoms • Age 45 or over where symptoms are worsening

Yes

No

Please provide more information below.*

Health

Are you taking any prescription-only medicines, alternative medicines or recreational drugs?*

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 known allergies to any medicine or substances?*

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 other health problems or conditions that you think we should know about? (e.g. Myasthenia Gravis, any enzyme deficiencies or recent major operations etc.)*

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):*

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

Personal*

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.

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Lansoprazole 30mg X 28 Capsules quantity

Category: Dyspepsia

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

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