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?

Have you been diagnosed with IBS by your doctor?

Please select the symptoms that you are suffering from:

Please select any of the following that describe your IBS symptoms:

How long have you suffered from these symptoms?

Does your abdominal pain occur with any of the following?

• Fever
• Blood in your stool
• Changes in bowel movement
• Feeling or being sick
• Low blood pressure
• Feeling faint

Do any of the following apply:

• You suffer from Ulcerative colitis or Crohn's disease
• You have a family history of bowel cancer or bowel polyps
• You have recently developed new symptoms or your symptoms have become worse

Do you suffer from any of the following symptoms:

• First time symptoms over 40 years of age
• 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)
• Iron deficiency (anaemia)
• Difficulty swallowing
• Pain in the stomach or gut that is always present
• Gastric or stomach ulcers
• A swelling or lump in your stomach or bottom
• Tiredness and lack of energy
• A complete inability to pass stools (intestinal obstruction)

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

• 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 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.