Have you ever been diagnosed with IBS by your GP?

Yes No

Select atleast one option

Have you been prescribed IBS medication before?

Yes No

Which IBS medication have you been prescribed (please state name, strength and the dosage)?

Select atleast one option

What symptoms are you suffering from? Please tick ALL the symptoms you suffer from:

stomach pain and spasms
unexpected weight loss
persistent diarrhoea or alternating constipation and diarrhoea
flatulence (wind) and feeling bloated
blood in the stools or vomit
difficulty swallowing
pain in the stomach or gut that is always present
tiredness and lack of energy
a complete inability to pass stools
small, hard stools
your symptoms often get worse after a meal
your symptoms are relieved by passing a stool

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any other IBS symptoms?

Yes No

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

For how long have you been suffering from IBS symptoms?

for less than a month
for 1-3 months
for 6-12 months
for more than 1 year

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Does any of this apply to you?

Yes No

you have kidney or liver problems;
you suffer from any condition that we should know about;
you suffer from ulcerative colitis or Crohn's disease;
you have a family history of bowel cancer or polyps;
you are over 40 years old and experience IBS symptoms for the first time;

Can you please provide more details?

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or planning to get pregnant or start breastfeeding while taking this medication?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

When was the last time you were reviewed by your doctor regarding IBS?

less than 3 months ago
3-6 months ago
6-12 months ago
more than a year ago

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to mebeverine, alverine citrate or to any of the ingredients contained in IBS medication?

Yes No

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any medication?

Yes No

Please provide the name, dosage and the reason why you are taking that medication or medications.

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you agree to the following?

Yes No

You answered truthfully to all the questions and you are aware that any incorrect information you provided might present a danger to your health;
You will seek medical attention if you experience any unusual side effects;
If your condition gets worse or does not improve while taking this medication you will contact your doctor immediately ;
The treatment is solely for your own use ;
You will read the patient information leaflet supplied with your medication;

We are unable to prescribe you this medication.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Please tick the boxes to confirm the following:

I confirm that I am over 18 and I agree to the Terms and Conditions and the Privacy Policy.

You must accept the terms and conditions to continue!

Medical Assessment