Raf

About You

Are you registered with a GP practice in the UK?

Yes No

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.)

Yes No

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

Yes No

Symtoms

How long have you been a smoker?

Select the most appropriate answer:

Up to 6 months
6 months - 2 years
2 - 5 years
5 years +

How many cigarettes do you smoke daily?

Select the most appropriate answer:

Up to 5
5 - 10
11 - 15
16 - 20
20+

Have you previously tried to quit smoking?

Yes No

Please tick all that apply to you.

I smoke even if I am so ill that I am in bed most of the day
I find it difficult to refrain from smoking in places where smoking is forbidden
I smoke more in the morning
I smoke within 30 minutes of waking

Health

Do you have any liver problems?

Yes No

Do you take any of the following medication, antiepileptics, antidepressants, antipsychotics, cimetidine, theophylline or warfarin?

Yes No

Are you currently using Nicotine Replacement Therapy or any form of Varenicline (Champix) or Bupropion (Zyban) to help stop smoking?

Yes No

Do you understand that you should start taking Champix 1-2 weeks before you stop smoking?

Yes No

Do you suffer from any of the following:

Depression, anxiety or any other psychiatric condition or mental health issue.
A history of seizures or epilepsy.
Heart disease or stroke.

Yes No

Are you aware that Champix:

Is not recommended for use with other smoking cessation therapies including nicotine replacement methods (such as patches and gums) and e-cigarettes.
May increase the effects of alcohol.
Can cause drowsiness and dizziness. You should not drive or operate machinery if you are affected.

Yes No

Are you pregnant or breastfeeding?

Yes No

Why do you want to quit smoking?

Medication

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

Yes No

Do you understand that when starting Champix treatment you should start with a 2 week starter pack?

Yes No

Are you aware that:

You are ordering the Champix Starter Kit to initate Champix stop smoking therapy.
It should only be used by those that are not currently taking Champix.
It should be used for 2 weeks before switching the Champix 1mg tablets for continuation therapy.

Yes No

Are you aware:

You should stop smoking on a date between day 8 and day 14 of your Champix Starter Pack.
If this you are unable to do this, your quit date should be no later than 5 weeks into treatment with Champix.

Yes No

Agreement

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.

Yes No

Medical Assesment Stop Smoking