Acid Reflux & Heartburn

Please complete your confidential clinical assessment. Evaluated by GMC & GPhC registered healthcare professionals.

About You

The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.

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Are you registered with a GP practice in the UK? *

Do you give us consent to write to your GP for approval of this supply and to share information we hold about you? *

(The information entered below in the medical assessment form will be treated with utmost confidentiality whilst being reviewed by the prescriber. It will also provide the prescriber with important information which will help them make an informed decision in deciding if the treatment is considered to be suitable for you).

Do you believe you have the capacity to make decisions about your own healthcare? *

Symptoms

Please answer the following medical questions to help us assess your suitability for treatment.

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Are you experiencing acid reflux at least twice a week? Symptoms include: *

Heartburn – a burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours
Chest pain, especially after bending over, lying down or eating
Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat
Feeling of food ‘sticking’ in the middle of the chest or throat

Are you experiencing any of the following?: *

difficulty swallowing
unintentional weight loss
abdominal swelling
persistent vomiting
severe/persistent diarrhoea
vomiting blood
blood in your stools or black, tarry stools
have iron deficiency anaemia
severe liver problems

Health

Final questions about your treatment preferences and expectations.

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Do you have an allergy (hypersensitivity) to medicines containing proton pump inhibitors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)? *

Are you breast feeding or pregnant or possibly pregnant? *

Do you have any of the following conditions: *

Osteoporosis
Liver problems
Gastric cancer
Hypomagnesaemia (low magnesium in the blood)

Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor? *

Medication

Final questions about your treatment preferences and expectations.

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Are you currently taking any medication (including over the counter, prescription or recreational drugs)? *

Are you taking any of the following medications?

NSAID anti-inflammatory painkillers (e.g. ibuprofen)
Ketoconazole, itraconazole, posaconazole or voriconazole (used to treat infections caused by a fungus)
Digoxin (used to treat heart problems)
Diazepam (used to treat anxiety, relax muscles or in epilepsy)
Ulipristal (used as emergency contraception or treatment for fibroids)
Phenytoin or Fosphenytoin (used in epilepsy)
Medicines that are used to thin your blood, such as warfarin or other vitamin K blockers.
Rifampicin (used to treat tuberculosis)
Atazanavir, Rilpivirine, Tripranavir, Saquinavir, Nelfinavir, Raltegravir (used to treat HIV infection)
Ledipasvir (used for Hepatitis C treatment)
Ciclosporin or Tacrolimus (in cases of organ transplantation)
St John’s wort (Hypericum perforatum) (used to treat mild depression)
Cilostazol (used to treat intermittent claudication)
Clopidogrel (used to prevent blood clots (thrombi))
Vitamin B12, Cyanocobalamin, Hydroxocobalamin
Erlotinib, Dabrafenib, Lapatinib or Pazopanib (for cancer treatment)
Clarithromycin (an antibiotic)
Methotrexate (for cancer or rheumatoid arthritis treatment)
Escitalopram (an antidepressant)
Clozapine (for schizophrenia)

Agreement

Final questions about your treatment preferences and expectations.

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Do you understand that healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable? *

Do you understand that acid reflux treatment supplied through this service can only be used for the short-treatment of gastroesophageal reflux disease (GORD) also known as heartburn/acid indigestion for a maximum of 28 days? *

Do you understand that if you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment? *

Do you agree to the following? *

I confirm I am over 18 years old.
The medicine ordered is for my sole use only.
I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.
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.
I consent to being contacted by telephone or email should the doctor or pharmacist require further information to assess my order.
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You are aware you will be subject to an ID check to verify your ID via LexisNexis Risk Solutions.

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Treatment Categories

About & Help

Acid Reflux & Heartburn

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Health

Medication

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