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

Do you suffer from travellers' diarrhoea?

Yes No

Which country(s) are you visiting?

Health

Do you have any of the following conditions listed: Reduced heart function, slow or irregular heartbeat, Low potassium or magnesium in your blood and Prolonged QT interval?

Yes No

Do you suffer from epilepsy or any other neurological problems?

Yes No

Do you have any stomach problems or inflammatory bowel disease?

Yes No

Do you weight less than 45kg (7 stone, 1 Ib)?

Yes No

Do you have an allergy or hypersensitivity to Azithromycin?

Yes No

Are you taking any of the following medication?

Ciclosporin
Digoxin
Ergotamine
Terefenadine
Dispopyramide
Rifabutin
Coumarins

Yes No

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

Yes No

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

Yes No

Do you smoke or drink alcohol?

Yes No

Medication

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

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 Travellers Diarrhoea