Acid Reflux Treatment & Heartburn Relief consultation

Do you have symptoms that feel like acid reflux or heartburn such as pain in the upper stomach, feeling full quickly or a burning sensation in your chest?

Yes

This question is required and must be answered.

How long have you been having symptoms of acid reflux or heartburn (if any)?

Do you ever feel chest pain or heartburn when you exercise or are active?

Yes

This question is required and must be answered.

Are you over 55 and recently developed indigestion that hasn’t improved with treatment?

Yes

This question is required and must be answered.

Have you ever been tested for a stomach infection called H. Pylori?

Yes

This question is required and must be answered.

Have you ever had a procedure where a camera was used to look inside your throat or stomach (endoscopy)?

Yes

This question is required and must be answered.

Have you experienced any of these symptoms: bloating, nausea, vomiting, blood in vomit, black stools, unexpected weight loss, or trouble swallowing?

Yes

This question is required and must be answered.

Please confirm you understand that these lifestyle changes can help reduce indigestion: cutting down alcohol, avoiding spicy or fatty foods, keeping a healthy weight, stopping smoking, and raising the head of your bed.

Yes, I confirm

This question is required and must be answered.

I confirm that if my symptoms do not get better after 4 weeks of treatment I will consult my GP or own doctor

Yes, I confirm

This question is required and must be answered.

What is your height and weight?

Height

Height in centimeters

Weight

Weight in kilograms

Do you have high or low blood pressure?

Yes

This question is required and must be answered.

Do you smoke any tobacco products or use a nicotine containing vape?

Yes

This question is required and must be answered.

Do you drink alcohol?

Yes

This question is required and must be answered.

Do you take any medication, or have any medical conditions?

Yes

This question is required and must be answered.

Do you have any disabilities or special needs that we should be aware of, in order to provide you with the best possible care?

For Example: ADHD, ASD or Learning Difficulties. This will help our clinicians and pharmacy team to allow you access all our services safely.

Yes

This question is required and must be answered.

Do you have any known allergies? E.g. Penicillin, egg protein or peanuts or an allergy to the ingredients in some medication eg lactose?

Yes

This question is required and must be answered.

Do you have any liver or kidney problems including reduced kidney function or chronic liver disease?

Yes

This question is required and must be answered.

Do you give us permission to inform your NHS surgery, about this prescription?

Yes

It is important to tell your doctor of any medication you have been prescribed for them to be able to treat you appropriately, safely and to avoid any drug interactions.

I am over 18 and this is for my sole use. I understand this is a non emergency service. I confirm I have answered all questions accurately and understand the doctor will use this information to prescribe safely for me.

Yes, I confirm

This question is required and must be answered.

By providing us with your details you confirm that you have read, understood and agreed to the legal terms and you consent to the sharing of your data to use our service.
I consent to treatment and an identity check
I give consent for the pharmacist to access and store relevant information from my NHS summary care record which may be needed to safely prescribe.
I agree to read the Patient Information Leaflet supplied with the medication.

Yes, I confirm

This question is required and must be answered.

Online Consultation for Acid Reflux Treatment & Heartburn Relief

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