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?

Is your travel sickness new in onset or have you suffered with it long-term?

Select the most appropriate answer:

Do your symptoms continue for more than 24 hours after you stop travelling?

Do you have an allergy?

Have you been diagnosed with heart, liver or kidney disease?

Are you pregnant or breast feeding or intending to become pregnant or start breast feeding whilst taking this medication?

Do you smoke or drink alcohol?

Do any of the following apply:

• You are allergic or hypersensitive to hyoscine (Scopoderm).
• You have used hyoscine (Scopoderm) before and suffered serious side effects.
• You are using hyoscine (Scopoderm) to treat sickness that is not caused by motion/travel.
• You suffer with glaucoma.

Do you suffer from any of the following symptoms:

• Vomiting repeatedly for more than two days?
• Inability to keep down any fluids due to repeated vomiting?
• Vomit that is green (this could mean you are bringing up a fluid called bile, which suggests you may have a blockage in your bowel)?
• Signs of severe dehydration, such as confusion, a rapid heartbeat, sunken eyes and passing little or no urine?
• Fast or unexpected weight loss?
• A fever, chills, headache or diarrhoea?

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

Do you take any of the following medicines:

• Antihistamines.
• Tricyclic antidepressants (such as amitriptyline and imipramine).
• Amantadine.
• Quinidine.
• Belladonna alkaloids (such as atropine, hyoscyamine, and scopolamine).

Do you agree to seek immediate medical attention if you experience any of the following symptoms:

• Sudden, severe abdominal (tummy) pain.
• Severe chest pain.
• Blood in your vomit or what looks like coffee granules.
• A stiff neck and high temperature (fever).
• A sudden, severe headache that's unlike any headache you've had before.

• 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.