Enlarged Prostate Consultation

Are you aged between 45 and 75 years old and male? *

Yes No

Have you been diagnosed with Prostate Enlargement (also known as Benign Prostatic Hyperplasia) by your GP or Doctor? *

Yes No

Have you taken Tamsulosin to treat prostate enlargement before? *

Yes No

Have you experienced any of the following symptoms for the last 3 months or more? *

Please select all symptoms that apply (You can select more than one option)

Difficulty starting to urinate Straining to urinate and/or unintentionally leaking urine Weak flow or where urination is starting and stopping Frequent or urgent need to urinate Getting up regularly in the night to urinate Not completely emptying your bladder None of the Above

Do you have a fever or high temperature associated with the any symptoms? *

Yes No

Have you ever had a history of?:

Postural hypotension ( Low blood pressure on sitting/standing up)
Heart problems including heart failure, unstable angina or left-ventricular outflow obstruction such as aortic stenosis
Kidney or liver disease
Uncontrolled diabetes
Undiagnosed cloudy/blurred vision
Urinary incontinence

*

Yes No

Please provide more details below

Have you ever had surgery for the prostate? And/Or do you currently have any surgery pending for glaucoma or cataracts? *

Yes No

Please provide more details

Is your urine cloudy? and/or is there any pain when you urinate? *

Yes No

Please provide more details

Have you had a PSA test (a test for Prostate cancer) in the last 5 years? *

Yes No

Have you ever had an allergic reaction to Tamsulosin? Or have any other allergies we should be aware of? *

Yes No

Please provide more details on all your allergies

Are you currently taking any of the following medications? *

Please select all options that apply (You can select more than one option)

Doxazosin Indoramin Prazosin Terazosin None of the Above

Are you currently taking or have recently finished taking (in the last month) any OTHER medication whether prescribed or not including over-the-counter, herbal, or recreational drugs? *

Yes No

Please provide more details on all medications you are taking or have recently stopped taking

Is there any other medical or non-medical information we should be aware of? *

Yes No

Please provide more details

If you are requesting this medication for more than 6 weeks, we are required to inform your GP that you are taking this medication so they have a full and accurate picture of any medication you are receiving from us long-term. Do you consent for us to contact your GP? (We will request your GP details after you place your order) *

Yes No

Before you continue

Please read the following statements:

I have answered all the above questions in full accurately and truthfully and I will contact Pharmacy if there is any change to the above questions. I understand any incorrect information may be detrimental to my health
I am requesting treatment for myself and any prescribed treatment will be for my sole use
The information provided will be collected and processed in accordance with GDPR regulations. I agree for my information to be processed by the Pharmacy in order to provide any treatment and that the prescribers will ultimately have the final decision whether to prescribe any medication
If I suffer any side effects from my treatment I will contact Pharmacy and or my GP immediately
I will read the patient information leaflet before taking the medication and I will contact a health care professional if I have any questions relating to my treatment or the information contained within it
I should inform my GP that I am taking this medication
I am aware medication to treat prostate enlargement may cause dizziness or weakness and this may affect performance of skilled tasks such as driving. I agree that in the event of this, I should sit or lie down and not operate any machinery or drive until the symptoms have gone
I understand I should have my blood pressure checked regularly as well as testing for diabetes, high cholesterol or hormone imbalances

I agree to all of the above statements