Have you been diagnosed with asthma by your doctor?

Yes No

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

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 your asthma?

3-6 months
Less than 3 months ago
6-12 months
More than a year ago

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you currently using a reliever inhaler (blue inhaler/Salbutamol/Ventolin)?

Yes No

What is your current prescribed dose (e.g. one puff twice a day)?

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you been given inhalers within the last 2 months (including from your GP, hospital, online etc.)?

Yes No

Can you please provide more details?

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Have you had emergency treatment or had to visit A&E due to your breathing problems in the last year?

Yes No

Can you please provide more details?

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you know how and when to use your inhaler? (please check whether you are using your inhaler correctly by watching the video here

Yes No

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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

Rarely or almost never
Less than three times per week
More than three times per week

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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

One or more nights per week
Rarely/Never

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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

Rarely or almost never
Less than three times per week
More than three times per week

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you suffer from any of the following?

Yes No

high blood pressure ;
an overactive thyroid gland ;
a history of heart problems such as an irregular or fast heartbeat or angina;

Can you please provide more details?

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any of the following?

Yes No

Xanthine derivatives (such as theophylline) or steroids to treat asthma;
Water tablets (diuretics) to treat high blood pressure or a heart condition ;

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

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you taking any other medication including other asthma medication (e.g. other inhalers or tablets)?

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. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you allergic to salbutamol or have you ever experienced any reaction with an asthma inhaler?

Yes No

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Are you pregnant or breastfeeding or may become pregnant or breastfeeding while using this treatment?

Yes No

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

In order for us to provide an inhaler, we are required to inform your regular GP. Do you give us consent to inform your GP about the supply of this medication?

Yes No

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Please enter your GP's full name and surgery address so we can contact them to advise of the medication you have ordered.

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

Do you understand that you must seek medical attention or speak to your doctor immediately if…

Yes No

your breathing is getting worse;
your asthma does not improve within 1 hour of using your inhaler ;
you start getting a tight chest;
you have daytime asthma symptoms, you wake up during the night with asthma or your asthma is interfering with your usual activities;

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

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 will inform your doctor about any unusual side effects;
The treatment is solely for your own use;
You will read the patient information leaflet supplied with your medication;
You will not exceed the maximum daily dose of this medication ;
We can only supply you with a maximum of 2 inhalers (6 months supply). After that we would need a further permission from your regular GP to supply you again;
You have answered truthfully to all the questions and you are aware that any incorrect information you provided can present a potential danger to your health;

We are unable to prescribe you this medication. This medication is for people who have already been prescribed this.

For further information kindly contact our patient support team:

0207 867 3932

email help@clickpharmacy.co.uk.

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Medical Assessment