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November 26, 2019 / bymedical / 0

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Are you a male or female? Male Female
What is your date of birth?
What is your height?
What is your weight?
What is your blood pressure?
Do you have any allergies? Yes No
Do you smoke, drink alcohol or take any recreational drugs? Yes No
Do you take herbal, homeopathic or ayurveda medicine? Yes No
What diagnosis/treatment do you require medicine for and what medicine has your doctor recommended in the past?
Have you seen your Doctor about the present condition? Yes No
Is your doctor aware of the medicine you intend to buy and are you going to inform your Doctor that we issued you this medicine? Yes No
Have you taken this medicine before with a prescription in less than 6 months ? Yes No
Do you suffer from any cardiovascular (heart) disease or have you ever had a stroke? Yes No
Do you suffer from transient ischaemic attack(s)? Yes No
Do you suffer from liver, kidney or gallbladder disease? Yes No
Do you suffer from stomach or bowel disorders (IBS), colitis or crohns? Yes No
Do you suffer from thyroid disease? Yes No
Do you suffer from asthma, bronchitis, emphysema or COPD? Yes No
Are you pregnant, breast feeding or planning to get pregnant? Yes No
Do you suffer from diabetes? Yes No
Do you suffer from high cholesterol or triglycerides? Yes No
Do you have any other disease, disorder or medical problem that the prescribing doctor needs to know? Yes No
Are you currently taking any other medication, other than this selected medicine, including prescribed and over the counter? Yes No
Do you currently have or ever had any problems like allergic reaction, side-effects or drug abuse by using this or other medicines? Yes No
Have you ever had any minor or major surgery? Yes No
Do you suffer from heartburn? Yes No
Have you had any test in the past 12 months (such as Blood test, breath test, stool test, camera trhough the mouth, camera through the back passage)? Yes No
How long do you expect this medication to last you? Yes No
Do you suffer from any suicidal thoughts or psychic problems? Yes No
Have you had any psychiatric referrals or consultations in the last 3 year? Yes No
Do you take any antidepressants? Yes No
Please advise us upon the number of tablets left with you, whether it is prescribed by this online doctor service or from any other services including your own GP or Family/Hospital Doctor?
Have you seen your General Practitioner (GP) or Family/Hospital Doctor about the condition you require this medication for? Yes No
Have you taken this requested medication before, and was it initiated by your G.P or Family/Hospital Doctor? Yes No
I agree to read the relevant patient information leaflet before taking any medication if I am prescribed.
I give permission to allow the company to use my personal data strictly for processing my order which includes for use in credit/debit card processing, credit reference (CRA) and fraud prevention (FPA) agencies to help them make decisions on the legitimacy of my order.
Would you like to opt in to receive reminders for re-ordering of your repeat monthly medication? Yes No
Would you give us permission to contact your doctor if we need to discuss your treatment and to keep them informed about any medications prescribed for you? Yes No
Terms & Conditions I confirm that I'm over 18 and I agree to the terms and condition

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