Can you please tell us what symptoms are you suffering from? Please tick all the symptoms that apply to you

one or more painless growths or lumps around your vagina, penis or anus
itching or bleeding from your genitals or anus
a change to your normal flow of pee (for example, sideways)
a sexual partner who has genital warts (even if you have no symptoms)
pain when urinating
discharge from the penis or vagina
warts located internally (inside the urethra, vagina or anus)
open sores or wounds near your warts
bleeding between periods or after sex (women only)

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 warts?

less than a month
1 to 6 months
6 to18 months
longer than 18 months

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.

Have you been treated for warts before or are you still treated now?

Yes No

Please state the name of the treatment you have been using before or you are using at the moment:

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.

Is the total area of your warts larger than 4cm² (the size of a 50p coin)?

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 pregnant or breastfeeding or planning to get pregnant or start breastfeeding?

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.

Does any of the following apply to you?

Yes No

You have had your current outbreak for more than 18 months;
You have tried treating this outbreak of warts and it hasn't been effective;
You have problems with your immune system;
You have received an organ transplant;
You have an abnormal blood count;

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 aware of the following?

Yes No

You should not use Warticon, Condyline or Aldara until the area to be treated has healed after previous drug or surgical treatment;
Warticon and Condyline should not be used for more than 4 treatment cycles (in case of Aldara for more than 16 weeks) for a single outbreak of genital warts ;
You should not use Warticon, Condyline or Aldara if you have used it before and suffered severe side effects or an allergic reaction;
You should not put a dressing or plaster over an area treated with Condyline, Warticon or Aldara;
you answered truthfully to all the questions and you are aware that any incorrect information you provided might present a danger to your health;

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 will seek medical attention if you experience any unusual side effects;
if your condition gets worse or does not improve while using 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:

If you have warts around the anus we recommend using Aldara. Please select this when you're asked to choose your treatment at the end of this questionnaire. Please tick to continue.

You must accept the terms and conditions to continue!

Medical Assessment