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  1. Home
  2. Acid Reflux
  3. Consultation

Your Health

About You

1

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? *

2

What is your height? *

3

What is your weight? *

Your symptoms

4

Do you understand that we are not able to offer treatment to those over the age of 65? *

5

Do you currently suffer with heartburn, indigestion, or acid reflux? *

6

How long have you suffered from acid reflux/heartburn? *

7

How often do you suffer from acid reflux/heartburn? *

8

What causes your symptoms? *

9

Have you had this condition diagnosed by a doctor? *

10

Have you had any other investigations about your symptoms? *

11

When was the last time you had this treatment prescribed by your GP? *

12

How often do you use this treatment? *

Your health

13

Do you have any other medical conditions? *

14

Do you have any allergies? *

15

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

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

Your Medication

16

Do you take any of the following medication? *

  • Nelfinavir, atazanavir, saquinavir or nay HIV drugs
  • Antifungal treatments
  • Clarithromycin
  • Digoxin
  • Diazepam
  • Phenytoin
  • Warfarin or any other anticoagulants
  • Rifampicin
  • Tacrolimus or other immunosuppressants
  • St John’s Wort
  • Cilostazol
  • Clopidogrel

17

Do you take any other medication? *

A Bit More About You

18

Do any of the following apply to you? *

  • You are experiencing unexplained weight loss
  • You are experiencing loss of appetite
  • You are experiencing trouble swallowing
  • You are experiencing inflamed stomach or tenderness in the stomach
  • You are experiencing accompanying back pain
  • You are experiencing constipation
  • You are experiencing nausea and vomiting, especially if there is blood in the vomit
  • You are experiencing chest pain
  • You are experiencing black or blood-stained poo
  • You are experiencing diarrhoea
  • You are experiencing bleeding from the rectum
  • You suffer from anaemia (symptoms of anaemia include fatigue, weakness, shortness of breath, dizziness or light-headedness, cold hands and feet, shortness of breath, irregular heartbeat, pale skin)
  • You have a family history of cancer (if so, please let us know which cancer)
  • You are age 55 or over with symptoms for the first time, or first time in 12 months
  • You have liver problems
  • You have experienced skin reactions from treatment
  • You have a history of gastric ulcers or jaundice
  • You have osteoporosis
  • You have increased magnesium levels in the blood
  • You have had stomach surgery or any form of gastric surgery

Agreement

19

Do you understand that if you experience any of the above, you should stop treatment and seek medical advice? *

20

Are you aware that: *

Stress, being overweight, smoking, drinking, eating habits and depression can exacerbate symptoms of acid reflux; and that managing stress, losing weight, avoiding trigger foods, stopping smoking, reducing alcohol consumption, and eating smaller meals with the evening meal 4 hours before bed, can all help to ease symptoms? You should read this self help guide on indigestion.

21

Do you agree that you will consult your doctor if: *

  • Your symptoms change or get worse
  • Treatment no longer provides relief
  • You experience side effects from treatment
  • You are using treatment for the first time and your symptoms do not get better after one week
  • You require treatment more than four times a week
  • You start to experience any symptoms mentioned in question 18

22

Do you agree that? *

  • 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 conditions change 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.
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