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?

Do you know the cause of your pain?

Please describe any symptoms you are experiencing, including the type of pain.
FOR EG sharp, dull, throbbing, aching, cramping, shooting, tender, redness, swelling, bruising, inflammation, weakness, nausea

On a scale of 1 – 5, how would you rate the severity of your pain?

How often do you experience this type of pain?

What makes the pain worse?

what makes the pain better?

Are you aware that if you should speak to your doctor in any of the following circumstances:

• Your pain does not improve with treatment.
• Your pain is getting worse.
• Your are in severe pain.
• Your pain is spreading to other areas of the body.
• Your pain is having a significant long-term impact on your quality of life.

Which statement below best fits how often you intend to take Naproxen?

Do you take any of the following medicines:

• Non-steroidal anti-inflammatory drugs (NSAIDs) (e.g. aspirin, diclofenac, ibuprofen or naproxen).
• Medicines that prevent blood clotting (e.g. warfarin or heparin).
• Corticosteroids (e.g. presnisolone or hydrocortisone).
• Medicines for high blood pressure or water tablets (diuretics).
• Ciclosporin or tacrolimus (to suppress the immune reaction).
• Mifepristone.
• SSRI antidepressants (e.g. citalopram, paroxetine, sertraline or fluoxetine).
• Zidovudine (to treat HIV or AIDS).
• Quinolone antibiotics (e.g. ciprofloxacin).
• Probenecid (for gout).
• Methotrexate (to treat cancer or rheumatism).
• Bisphosphonates (e.g. alendronic acid).
• Colestyramine.
• Lithium (to treat depression or mania).
• Medicines to treat epilepsy (e.g. phenytoin).
• Sulphonamides (e.g. sulfamethoxazole).
• Medicines that reduce your blood sugar (e.g. gliclazide or glibenclamide).
• Cardiac glycosides (e.g. digoxin).

Do any of the following apply:

• You have, or have previously suffered from, stomach or duodenum ulcers or bleeding in the stomach or intestines.
• You have liver, kidney or heart problems.
• You are on a low potassium diet.
• You have a history of gastrointestinal disease (e.g. ulcerative colitis, Crohn's disease).
• You have high blood pressure.
• You have experienced shortness of breath, worsening of asthma, allergic rash or an itchy, runny nose when taking ibuprofen, aspirin, naproxen or other similar medicines.
• You have systemic lupus erythematosus or other connective tissue disorders.
• You have a blood clotting disorder.

Are you pregnant or breastfeeding?

Are you currently seeing, or have you recently seen, a hospital specialist?

Have you had any diagnostic investigations for your condition? (X-Ray, MRI etc.)

Have you previously tried any over-the-counter pain medication?

Have you tried non-drug treatments for your pain, such as;

• Physiotherapy
• Chiropractic
• TENS
• Hydrotherapy
• Massage
• Acupuncture?

Are you drinking alcohol everyday?

Have you ever experienced difficulty stopping pain relief medication?

Do you have a history of drug or alcohol dependence?

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

Are you aware that:

• Naproxen is an anti-inflammatory painkiller that works best for joint and muscular pain or similar conditions.
• Naproxen should be taken with or after food.
• Naproxen should not be taken with any other anti-inflammatory painkillers such as ibuprofen, aspirin or diclofenac.

• 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.