Have you ever been diagnosed with acid reflux by your GP?

Yes No

Select atleast one option

Have you been prescribed acid reflux medication before?

Yes No

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

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 over the age of 65?

Yes No

Select atleast one option

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.

What symptoms are you experiencing? (please tick all the symptoms that apply to you):

burning sensation in the middle of your chest
unpleasant sour taste in your mouth
a cough or hiccups that keep coming back
a hoarse voice
bloating or feeling sick
loss of weight for no reason
problems swallowing
vomiting food or vomiting blood
passing black stools (blood-stained faeces)
severe or persistent diarrhoea

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 acid reflux?

less than 3 months ago
3-12 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.

How often are you experiencing the acid reflux symptoms?

once or twice per week
three times per week
more than three times per week

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 omeprazole, lansoprazole, esomeprazole, pantoprazole, ranitidine or to any of the ingredients contained in acid reflux 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 of the following?

Yes No

HIV medication (such as nelfinavir);
corticosteroids;
NSAIDS (ibuprofen, naproxen…);
ketoconazole, itroconazole (antifungals);
any heart medication (such as propranolol, digoxin);
asthma medication;
epilepsy medication;
diabetes medication;
antidepressants;
blood thinning medication (warfarin, clopidogrel…);
rifampicin (used to treat tuberculosis);
methotrexate ;

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.

Are you taking any medication not mentioned above?

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 suffer from any of the following?

Yes No

stomach cancer;
kidney or liver problems;
acute porphyria;
diabetes;
osteoporosis;
any other condition we should know about;

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.

Do you agree to the following?

Yes No

if you get a rash on your skin, especially in areas exposed to the sun tell your doctor as soon as you can;
to contact your GP if you experience any other ill-effects like pain in your joints;
if your symptoms doesn’t improve after 2 weeks of treatment you should see your GP;
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;
the treatment is solely for your own use to treat acid reflux and for no other condition ;
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