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

Have you been diagnosed with hayfever (seasonal allergic rhinitis) by a doctor or nurse previously?

Yes No

What symptoms do you experience?

Do you experience persistent blood-stained discharge?

Yes No

Have you had a recent nasal/head injury in the past 4 weeks?

Yes No

Health

Have you had any recent surgical operation or injury to the nose or mouth?

Yes No

Are you allergic to Telfast (Fexofenadine)?

Yes No

Have you been diagnosed with any of the following?

Kidney or liver problems
History of heart problems such as an irregular or fast heartbeat or angina
Epilepsy

Yes No

Are you breast feeding or pregnant or planning to become pregnant in the next 6 months?

Yes No

Do you or your family have a history of eczema or asthma?

Yes No

Medication

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

Yes No

Have you taken Telfast (Fexofenadine) previously or have you tried taking an over the counter anti-histamine without success?

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 Hayfever