Treatment Questions | Pharma Aesthetics

Answer medical questions to order

Have you read the IBS medical information?

Yes No

Are you allergic to the treatment you are planning to order?

Yes No

Colofac and Fybogel Mebeverine contains mebeverine (allergy may be shared with alverine) Spasmonal contains alverine (allergy may be shared with mebeverine) Colpermin contains peppermint, peanut, and soya protein Some long term users of ispaghula (in Fybogel) develop an allergy to it Buscopan contains hyoscine

Have your IBS symptoms started for the first time in the last 2 years?

Yes No

Have your IBS symptoms started for the first time after the age of 40?

Yes No

Have you or anyone around you noticed weight loss not due to dieting?

Yes No

Have your IBS symptoms changed from the ones you are used to?

Yes No

Have you noticed new blood in your motions (stools)?

Yes No

Are you aware that only one antispasmodic should be used at a time?

Yes No

Mebeverine and alverine are antispasmodics.

Do you have slow/weak bowel muscles, tendency to spastic colon or paralytic ileus, narrowing, stoppage, or blockages in the gut?

Yes No

Do you have the condition Phenylketonuria?

Yes No

Have you been diagnosed with liver disease or ulcerative colitis?

Yes No

Do you have any of the following conditions?

Yes No

Myasthenia gravis Glaucoma Serious gastrointestinal disease Kidney disease Palpitations or heart disease Thyroid problems Epilepsy Bladder or bowel obstruction Are over 60 Treatment for severe sweating

Are you taking any of the following?

Yes No

These medications interact with loperamide: Ritonavir (for HIV) Itraconazole or ketoconazole (for fungal infections) Gemfibrozil (for high cholesterol)

Are you taking any of these medications:

Yes No

These medications interact with Buscopan: Tricyclic or tetracyclic antidepressants (older type antidepressants) Antihistamines Antipsychotics (for severe mental illness) medication e.g. haloperidol, fluphenazine Salbutamol (Ventolin), tiotropium, ipratropium, trospium (for asthma or COPD) Amantadine (Parkinson's disease, flu) Metoclopramide and domperidone (for nausea and vomiting) Linezolid (a specialist antibiotic - used very rarely) Disopyramide (to control the heart rhythm)

Are you aware that overuse of loperamide can lead to constipation or bowel obstruction?

Yes No

Loperamide can cause constipation.

Are you aware loperamide can sometimes cause drowsiness or dizziness?

Yes No

Caution needed if driving, cycling, or operating machinery.

Are you pregnant or breastfeeding?

Yes No

Do you have any further medical information or questions?

Yes No

Is there anything you do not understand or do you need further help?

Do the following apply to you?

Yes No

The medication is for my own use and I will not share with anyone else I will read the information leaflet supplied with the medication I am over 18 and I agree to identity verification checks I have completed this questionnaire myself and fully understand all the information My responses are honest and accurate, and I understand that this is necessary for a safe medical assessment I agree to the terms & conditions, privacy policy, data sharing policy & consent to cookies

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Irritable bowel syndrome

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