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Genital Herpes Questions

You and your symptoms

Are you over the age of 18 - 65?


Have you been diagnosed by your GP or Gum clinic with herpes?


Do you or have you suffered from any heart problems stroke, angina or any other heart related problems ?


Are you taking any medication that has been prescribed by your Gp/Doctor or Hospital ?


Do you give consent for us to contact you GP if required? (we need this to process any order for medication)


Current Health

Are you experiencing any of the following?


  • thrush
  • unintentional weight loss
  • chest pain
  • blood in your urine
  • pain when urinating
  • blood in your stools
  • urinary tract infections (UTI)
  • night sweats
  • fever

Do you have any allergies to medicines containing Aciclovir or Valciclovir?


Are you breast feeding or pregnant or possibly pregnant?


Have you ever been diagnosed with any of the following problems?


  • Liver problems
  • Kidney problems
  • Immunodeficiency conditions (eg. HIV)
  • Nervous system abnormalities
  • Any serious medical condition which may require immediate hospitalisation

Are you currently taking any of the following medications?


  • cimetidine (used to treat peptic ulcers)
  • probenecid (used to treat gout)
  • medicines that suppress your immune system (e.g. mycophenolate mofetil; ciclosporin; tacrolimus; methotrexate)
  • theophylline and aminophylline (used in asthma and other breathing problems)
  • zidovudine (used in HIV infection)
  • any medicine which affects the kidneys, including aminoglycosides, organoplatinum compounds, iodinated contrast media, pentamidine, foscarnet
Agreement

Do you agree to the following statements?


  • You must read the patient information leaflet supplied with your medication
  • You must 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.
  • The treatment is solely for your own use only.
  • You have answered all the questions in this short medical assessment accurately and truthfully to the best of your knowledge. You understand our doctor take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
all of our tests and treatments are price competative

You need to complete our short medical questionnaire so we can ensure the treatment you have selected is safe for you to use

all of our tests and treatments are price competative

Need Help?

If you need help with this medical questionnnaire call us on 07549286701

 
quality products assured across youth revisited

Quality products

all of our tests and treatments are price competative

Affordable prices

all of our pharmacies and and treatments purchased are from well known and trusted UK pharmacies

UK pharmacy

all of our tests and any other products purchased will be dispatched for a next day service

Express next day delivery

If you have any further questions about any of our products please feel free to contact us and we will do our best to help you.
Once you have your prescription we will be able to process your order through our trusted UK Pharmacy.