1 I understand that taking Diamox (acetazolamide) does NOT replace acclimatisation?
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Please write your explanation in the box below Yes No 2 Can you confirm you are aware of the following?
Diamox is not advised where normal acclimatisation recommendations are followed
Mountain sickness and serious HAPE and HACE can still occur whilst taking Diamox
Sleep disturbance of altitude is treated with 125mg (half a tablet) Diamox twice daily
Proper acclimatisation is important alongside this medicine
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Please write your explanation in the box below Yes No 3 I confirm I will read the dosage instructions and the patient information leaflet before taking this medication.
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Please write your explanation in the box below Yes No 4 Do you agree to Diamox (acetazolamide) being supplied to you ‘off label’?
If a medicine is used for an off label (unlicensed) purpose the manufacturer is not liable in case of adverse events. Prescribers take the responsibility for the prescribing.
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Please write your explanation in the box below Yes No 5 Are you allergic to Diamox (acetazolamide) or sulpha containing medication?
If you are not sure please check with your regular doctor before ordering Diamox (acetazolamide)
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Please write your explanation in the box below Yes No 6 Are taking any of the following medications?
Phenytoin or carbamezepine (anti-epileptic drugs)
Anti-coagulants (blood thinning drugs such as warfarin)
Medication to lower blood sugar (diabetic tablets)
Diuretics (tablets taken to remove fluid from the body)
Regular aspirin (more than occasional 1 or 2 aspirin every few days)
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Please write your explanation in the box below Yes No 7 Are you pregnant or breastfeeding or planning to become pregnant?
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Please write your explanation in the box below Yes No 8 Do you have any problems with your liver or kidneys?
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Please write your explanation in the box below Yes No 9 For organised groups, have you been advised to obtain Diamox (acetazolamide) by your group organisers?
For non-organised groups please answer ‘Yes’.
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Please write your explanation in the box below Yes No 10 Are you aware taking Diamox (acetazolamide) does NOT replace acclimatisation?
Above 3,000 metres (10,000 feet) ascend no more than 300-500 metres (1,000-1,500 feet) per day. For every 1,000 metres (3,000 feet) of ascent stop 2 nights before ascending further.
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Please write your explanation in the box below Yes No 11 Do you have any allergies?
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Please write your explanation in the box below Yes No 12 Do you agree to descend immediately and seek urgent medical help if you experience any of the following symptoms?
confusion
loss of consciousness
fever
ataxis (loss of coordination and balance that may be accompanied by abnormal speech)
sensitivity to light
rapid heart beat
change in mental state
breathing difficulties
weakness
chest tightness
crackling or wheezing when you breathe
a blue tinge to the skin
rapid and shallow breathing
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Please write your explanation in the box below Yes No 13 Are you aware Diamox (acetazolamide) is not advised where normal acclimatisation recommendations are followed?
Proper acclimatisation is the way to deal with altitude.
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Please write your explanation in the box below Yes No 14 Are you aware that we can only prescribe treatment for yourself?
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Please write your explanation in the box below Yes No 15 Are you aware people taking Diamox (acetazolamide) can still get mountain sickness including the very serious HAPE and HACE?
See the patient information leaflet for details.
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Please write your explanation in the box below Yes No 16 Are you aware the sleep disturbance of altitude is treated with 125mg (half a tablet) Diamox (acetazolamide) twice daily?
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Please write your explanation in the box below Yes No 17 Are you aware for early mild acute mountain sickness (headache, fatigue, dizziness, loss of appetite) the Diamox (acetazolamide) dose is 250mg (one tablet) twice daily?
Taking Diamox (acetazolamide) will help with these symptoms. The important thing is not to ascend until the symptoms resolve.
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Please write your explanation in the box below Yes No 18 Are you aware in situations where rapid forced ascent cannot be avoided the dose of Diamox (acetazolamide) is 125mg (half a tablet) twice daily?
Ascent of more than 500 metres (1,500 feet) a day above 3,000 metres (10,000 feet) is dangerous with or without Diamox (acetazolamide).
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Please write your explanation in the box below Yes No 19 Are you aware confusion, loss of co-ordination and extreme shortness of breath are serious symptoms requiring immediate descent and also possible, steroids, oxygen, hyperbarric oxygen and acetazolamide?
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Please write your explanation in the box below Yes No 20 Do you have, or have you ever had any of the following health conditions or problems?
Any type of glaucoma
Low blood levels of sodium or potassium
High blood levels of chlorine
Addison’s disease
Any lung or bronchial problems
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Please write your explanation in the box below Yes No 21 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 doctors 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
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Please write your explanation in the box below Yes No 22 What is the name of your GP surgery and do you consent to us contacting them about your treatment?
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Please write your explanation in the box below 23 Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability.
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Please write your explanation in the box below Yes No 