Rxpress

Melatonin / Jet Lag Consultation Form

Full name:

Date of Birth (DD/MM/YYYY):

Age:

Home Address:

Email:

Telephone:

NHS number (optional):

Name & Address of GP:

Would you like your GP to be informed of this consultation?
YesNo

Medical Questions

Do you have any allergies?
YesNo

If yes, please provide details:

Have you had a serious reaction or intolerable side effects to melatonin or any other medications before?
YesNo

If yes, please describe the product and the reaction:

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
YesNo

If yes, please provide details:

Are you breast-feeding?
YesNo

Do you have a medical history of any of the following?

• Renal / kidney problems

• Liver problems

• Seizure disorders (e.g. epilepsy)

• Neurological problems

YesNo

If yes, please provide details:

Have you been told by your doctor you have an intolerance to any sugars (e.g. galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
YesNo

If yes, please provide details:

Do you have any autoimmune diseases?
YesNo

If yes, please provide details:

Do you have diabetes?
YesNo

Are you a heavy smoker?
YesNo

Are you a heavy drinker?
YesNo

Please list all your current prescription medication including any medication you buy over the counter:

Please provide details of any recent or past medical history of note (e.g. other medical conditions that you have previously been treated for):

Travel Information

Destination country:

Arrival date:

Departure date: