Irritable Bowel Syndrome Consultation

Are you experiencing any of the following symptoms? *

Please select all that apply

Stomach cramps Bloating / distension / hardness Change in bowel habit (diarrhoea, constipation, or alternating) Excessive wind (flatulence) Other

Please provide more information on your symptoms

How often do you have these symptoms? *

How long have you experienced these symptoms? *

Have you been diagnosed with IBS by your doctor? *

Yes No

Please can you provide more information on why you think you have IBS?

When did you first start experiencing IBS? *

In childhood (Before 18 years old) In my 20s or 30s In my 40s After 50 years of age

Please can you provide more information on your symptoms and if you have discussed this with your own doctor and what they recommended?

We ask this because IBS symptoms after the age of 50 is less common and we need to rule out other conditions

How have your symptoms changed since they first began? *

Stayed the same Gradually getting worse and/or new symptoms developing Getting better Symptoms have gone

Please can you provide more details about how your symptoms are getting worse and/or any new symptoms

Can you also tell us if you have you spoken to your own doctor about this, or been referred to a hospital/clinic for any tests or if anyone in your immediate family have a history of gut problems?

Do you suffer from or does any of the following apply? *

I suffer from ulcerative colitis or Crohn's disease I currently have bowel cancer or bowel polyps I have a family history of bowel cancer or bowel polyps None of the above

Please can you provide more details about your condition

Please provide more information on when it was first diagnosed and if you are taking any medications for it?

Please can you provide more details about your bowel cancer or bowel polyps

Are you experiencing any of the following?

Unexpected weight loss
Unexplained rectal bleeding (especially if the blood is darker in colour)
Blood in the stools or vomit (may appear dark or sticky)
Difficulty swallowing
Pain in the stomach or gut that is always present
A swelling or lump in your stomach or bottom

*

Yes No

Please can you provide more details

Have you taken any treatments for your IBS? *

Yes No

What treatments have you taken for your IBS?

Please tick all that apply

Mebeverine (Colofac) Alverine (Spasmonal) Hyoscine (Buscopan) Peppermint Oil (Colpermin) Loperamide (Imodium) Others

What other treatments have you tried?

Did you have any side effects to these treatments?

Yes No

What side effects have you experienced?

Please provide as much detail as to which treatment(s) you have had side effects to

Do you suffer from any medical conditions? *

Yes No

Please can you provide more details on your medical history

Are you currently taking any medication, whether prescribed or not by your doctor, including over-the-counter medication, remedies, or recreational drugs? *

Yes No

Please can you provide more details on all medications that you are taking or have recently finished taking

Do you have any other allergies we should be aware of? *

This includes any allergies to medications and their ingredients

Yes No

Please provide a full list of any allergies you have including allergies to medications and their ingredients

Are you pregnant, possibly pregnant, or breastfeeding? *

Answer No if you are Male

Yes No

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

Yes No

Please provide more information

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 and if I am not requesting the starting dose for that medication, I have taken the medication previously on that dose and without any side effects
I have or will 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. 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 agree to all of the above statements