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 use your inhaler more than two puffs, four times a day?

Yes No

Do you understand that this service is not suitable for treating urgent asthma symptoms?

Yes No

Have you been diagnosed with asthma by your doctor or nurse?

Yes No

Have you called an ambulance or had emergency treatment for breathing problems in the last year?

Yes No

If you currently use an inhaler, do you know how and when to use your inhaler?

Yes No

How many times a week are you using your reliever inhaler (blue inhaler/Salbutamol/Ventolin)?

Rarely/never
Less than three times per week
Three times or more per week

How often are you woken up at night by your asthma?

Never/rarely
One or more nights per week

How many days a week do you have asthma symptoms (eg cough, wheeze, shortness of breath, chest tightness)?

Never/rarely
Less than 3 days a week
3 or more days per week

Health

Has a doctor or nurse checked your asthma in the last 12 months?

Yes No

Do you have any other medical conditions (e.g. heart disease or diabetes)?

Yes No

Do you smoke?

Yes No

Are you pregnant or breastfeeding?

Yes No

Have you been given inhalers within the last 2 months (including those prescribed by your GP, hospital, online etc)

Yes No

Medication

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

Yes No

Do you understand that you must seek medical attention if your asthma does not improve within 1 hour of using your inhaler?

Yes No

Are you aware that you should attend an annual review of your condition with your GP every 12 months?

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 Asthma