Consultation

British ChemistConsultation

Q No.	Question	Answer
1	Are you female? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
2	Do you have an allergy to Aspirin, Mefenamic acid or any other anti-inflammatory medication? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
3	Are you taking any medication to treat diabetes? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
4	Do you have high blood pressure (above 150/90)? If you are unsure you can get this measured at your local pharmacy or GP practice. You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
5	Do you suffer from any of the following? • High temperature • Vaginal discharge • Irregular periods • Vaginal bleeding after sexual intercourse • Sudden severe abdominal pain • Pain in between periods You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
6	Do you suffer from any of the following? • Asthma • COPD (Chronic obstructive pulmonary disorder) • Liver disease • Kidney disease • Mild to severe heart failure • Galactose intolerance • Blood disorder • Epilepsy • Inflammatory bowel disease • Had major surgery You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
7	Are you taking any of the following medication? • Anti-coagulants (e.g warfarin, heparin) • Diuretics • Lithium (for depression) • Medicines for treatment of heart conditions (e.g Digoxin) • Any other NSAID (e.g aspirin, ibuprofen, diclofenac) • SSRIs (e.g fluoxetine, sertraline, for depression) You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
8	Do you smoke or drink alcohol? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
9	Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication? 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 seek medical attention if you experience any unusual side effects • The treatment is solely for your own use • You will read the patient information leaflet supplied with your medication • You will not smoke or drink alcohol while taking this course of medication 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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