Acid Reflux Consultation

Are you suffering from any of the following symptoms?

Heartburn (A discomfort, pain, acidic sensation, or burning pain in the chest area)
A sharp or gripping pain that may radiate to the throat and back, associated with acid regurgitation, exacerbated by eating large meals, bending over, or lying flat, especially in bed at night

*

Yes No

Does any of the following apply?

Experiencing these symptoms for the FIRST time
Your symptoms have recently changed
Have unexplained indigestion that HAS NOT responded to treatment

Yes No

Have you ever had an allergic reaction to omeprazole, esomeprazole, lansoprazole, NSAIDs or any other medication? Or have any other allergies we should be aware of? *

Yes No

Please provide more details on ALL of your allergies

Are you breastfeeding, pregnant, or possibly pregnant? *

If you are Male, please select No

Yes No

Does any of the following apply to you?

Are you Asthmatic or have ever been Asthmatic?
Are you taking Asprin or any medication that thins the blood (e.g Warfarin, Apixaban) or have any coagulation defects?
Are currently taking any other anti-inflammatory medication?
Are currently taking any steroid medication (e.g Prednisolone)?
Due to have surgery, an endoscopy, or a C-urea test

*

Yes No

Please provide more details

Regarding any medical conditions, do any of the following apply? *

Please select any of the following that applies (You can select more than one option)

Currently have or previously had a Gastric Ulcer or have Gastric Cancer Have a history of gastrointestinal disorders (e.g. ulcerative colitis, Crohn's disease) Have gastrointestinal bleeding or history of it None of the above

Are you currently taking any other medication, including prescription, over-the-counter, or herbal remedies (e.g. St John's Wort)? *

Yes No

Please list ALL medication you are currently taking

Is there any other information we should be aware of regarding your health or medical history? *

Yes No

Please provide more details

Before you continue

Please read the following statements:

I confirm these questions have been answered truthfully and accurately. I understand that any incorrect information may be detrimental to my health
I confirm the medication is for my personal use only and I should inform my GP of any treatment I receive from Pharmacy
I confirm I will take the medication as prescribed or directed for its intended use
I have read the patient information leaflet, and I will contact a medical professional if I have any questions or experience any side effects while taking the medication
All information provided will be handled in the strictest confidence in line with GDPR regulations. I am happy for Pharmacy to collect and use the information I provide for the purposes of providing treatment for my medical condition
I am happy to be treated by the prescribers and health care professionals at Pharmacy and the final decision on whether to provide treatment will be with the prescriber and or pharmacist
I understand if my symptoms do not improve after 2 weeks of starting this treatment, or my symptoms worsen, I should stop taking this medicine and consult my GP
I understand I should seek urgent medical attention if I experience difficulty swallowing, persistent vomiting, vomiting blood, blood in my stools, or significant unintentional weight loss
I understand that this medication should be taken before food, preferably in the morning, and that long-term use should be reviewed by a healthcare professional

I agree to all of the above statements