Consultation

British ChemistConsultation

Q No.	Question	Answer
1	Are you pregnant or breastfeeding or likely to become pregnant? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
2	Do you have any problems with your liver or kidneys? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
3	Have you been diagnosed with any of the following? epilepsy diabetes or impaired glucose tolerance significant liver or kidney disease (ask your doctor if not sure) autoimmune disease (body attacked by own immune system) You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
4	Do you have any allergies? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
5	Are you taking any of the following medications? fluvoxamine (an antidepressant) psoralens (treatment for psoriasis) cimetidine (treatment for stomach acid and ulcers) quinolones (type of antibiotic) rifampicin (type of antibiotic) carbamazepine (anti-epileptic treatment) benzodiazepines (various sedatives and sleeping tablets) warfarin (anticoagulant – blood thinning) You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
6	Do you have any medical conditions? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
7	Are you aware melatonin can cause drowsiness? Melatonin may impair driving and operating machinery. You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
8	Do you take any recreational drugs? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
9	Are you aware that there are various things that you can do to reduce some of the effects of jet lag alongside taking medication? These include: Slowly adjusting your schedule to the new time zone before you fly Getting plenty of natural light in daylight hours when you land Staying hydrated Not sleeping during the daytime even if you’re tired Sleeping at night time in the new time zone Using eye masks and earplugs to help with restful sleep if you experience insomnia You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
10	Do you agree to the following? You will read the Patient Information Leaflet supplied with your medication You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment The treatment is solely for your own use You are over the age of 18 and you have entered your own information for our identity verification checks You have answered all the above questions accurately and truthfully You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health You will inform your own GP of this purchase if appropriate You have read our privacy policy, cookie policy, patient agreement, data sharing agreement and Terms & Conditions You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
11	What is the name of your GP surgery and do you consent to us contacting them about your treatment? You must answer this question. You must answer this question. Please write your explanation in the box below
12	Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability. You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo

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