Chemist click

Your Health

Do you believe you have the capacity to make decisions about your own health; and that you do not require help to complete this consultation? *

Yes

What is your height? *

feet/inches

cm *

What is your weight? *

stones/lb

kg *

Stone *

How long have you been smoking? *

Up to 6 months

6 months - 2 years

2-5 years

5+ years

Other

How many cigarettes do you smoke daily? *

Up to 10

11-20

21-30

31+

Other

How soon after waking up do you smoke your first cigarette? *

Within 5 minutes

6-30 minutes

31-60 minutes

After 1 hour

Other

Have you previously tried to stop smoking? *

Yes

Are you pregnant, breastfeeding, planning pregnancy or at risk of pregnancy whilst taking this medication? *

Yes

Pregnancy risk may be defined as late period or unprotected sexual intercourse which may have taken place since your last normal period.

Do you have, or have you ever had any of the following? *

Yes

Epilepsy or seizures
Heart problems
Stroke
Conditions that affect your mental health
Kidney problems
An issue with substance misuse

Do you have any other medical conditions? *

Yes

Are you taking any of the following medication? *

Yes

Aminophylline
Theophylline
Chlorpromazine
Clozapine
Erlotinib
Methadone
Olanzapine
Riociguat
Warfarin

Are you taking any other medication or recreational drugs? *

Yes

Do you have any allergies? *

Yes

This includes if you have suffered any side effects from taking Champix in the past.

Do you understand that Champix should not be used with Nicotine Replacement Therapy (NRT)? *

Yes

Are you currently using Champix? *

Yes

Do you understand that the recommended course of treatment is 12 weeks? *

Yes

If you feel at the end of 12 weeks, there may a chance of relapse, a further 12-week course may be considered to help abstinence.

Do you understand that Champix may cause dizziness and drowsiness? *

Yes

You should not drive, operate machinery, or perform potentially hazardous activitites until you have assessed your response.

Would you like us to contact you to provide support with quitting smoking? *

Yes

Is there any additional information you would like to provide, or any questions you have? *

Yes

Are you aware that you must stop taking Champix and seek medical advice if you experience any of the following: *

Yes

Depression, suicidal ideation and behaviour, suicide attempts, or any changes to your mental health
Signs of a heart attack such as jaw pain, shortness of breath, chest pain/discomfort/tightness, backache, extreme fatigue, sudden sweating, heartburn, nausea/vomiting, pain travelling from your chest to your arm, shortness of breath, overwhelming sense of anxiety
Signs of allergy such as swelling of the face, lips, tongue, gums, throat, gums, throat or body and/or difficulty breathing, wheezing
Seizures
Skin reactions such as a rash or skin peeling
Any unusual side effects

Whilst you should seek urgent medical advice, you should also inform your GP and inform us if you experience any of the above. You should call 999 in the case of a medical emergency, or 111 for advice.

Are you aware that: *

Yes

Whilst drug intervention is effective, it is most effective when used in conjunction with behavioural support. You can visit www.nhs.uk/smokefree to receive a free Personal Quit Plan, and find out more information about how you can quit smoking
You must set a quit date and commit to it. Stopping smoking in one step gives the best chance of success. Taking the odd puff here and there almost always leads to going back to regular smoking
The first few days after quitting are often the most difficult, and you may experience withdrawal symptoms such as cravings, increased appetite, restlessness, irritability, depression, poor concentration, and disturbed sleep. These are common and will start to improve after the third or fourth day
Throughout the duration of this treatment, try to keep in mind the reason why you decided to quit
You should try to avoid scenarios that can cause cravings, such as stressful situations, being around other smokers and becoming intoxicated. Try to engage in short bouts of exercise, breathing techniques, talking to a friend or family member for support, changing your routine and keeping busy can help to reduce cravings
Putting on weight is a common barrier to stopping smoking. Stopping smoking does not directly impact weight, but people eat as a distraction to smoking and this causes weight gain. Weight can always be lost but the risks associated with continuing to smoke are greater than those associated with gaining a small amount of weight
You should read the Patient Information Leaflet for common side effects, and report any side effects and changes in your health and body to your GP, and via the Yellow Card Scheme

Do you agree that: *

Yes

You will read the Patient Information Leaflet supplied with your medication
You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical status changes during treatment.
You are over 18 and the treatment is solely for your own use
You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health
You are aware the decision about your treatment are for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber's
You will inform your GP that you have ordered this medication
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