Your Name (required)

We need a phone number so we can contact you regarding your medication if needed.

Your Gender
MaleFemale

Do you have a Prescription for the Online Consultation?
YesNo

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Are you/they breastfeeding?
YesNo

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Do you suffer from any heart problems?
(e.g. high or low blood pressure, previous heart attacks, angina, irregular heart rhythm)
YesNo

What is your blood pressure?
—Please choose an option—Normal - 90/60 to 139/89High - 140/90 or AboveLow - 90/60 or Below

Do you suffer from any kidney problems?
YesNo

Do you suffer from any liver problems?
(e.g. hepatitis, fatty liver, alcohol liver disease)
YesNo

Do you suffer from any hormone or sugar problems?
(e.g. diabetes, thyroid problems)
YesNo

Do you suffer from any mental health problems?
(e.g. anxiety, depression, personality disorder)
YesNo

Do you suffer from any neurological problems?
(e.g. parkinsons, previous stroke or mini-stroke)
YesNo

Please tell us about any operations you have had

What is your weight?
ImperialMetric

Are you currently taking any medications?

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Do you smoke?
YesNo

Do you drink Alcohol?
YesNo

Do you suffer from any allergies?
YesNo

Is there a history of any disorder that runs in the family?
YesNo

Would you like us to inform your GP of your consultation?
YesNo

Info: It is important that your GP is aware of any medication you are taking to allow them to provide you with the best and safest care. We advise that you inform your GP of any medication we prescribe.

Do you agree to read the patient leaflet before taking any medication prescribed to you? Agree?

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