Rxpress

Medicine Supply Consultation Form

Title:
—Please choose an option—MrMrsMissMsOther

Date of Birth (DD/MM/YYYY):

Age:

First Name:

Surname:

Home Address:

Email:

Telephone:

Name & Address of GP (optional):

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

Medical Assessment

Do you have any kidney problems?
YesNo
If yes, please provide details:

Do you have epilepsy?
YesNo

Have you ever had an allergic or anaphylactic reaction to sulphonamides or related medicines?
YesNo
If yes, please provide details:

Do you have any allergies?
YesNo
If yes, please describe the allergy/reaction:

Have you previously had, or do you have kidney stones?
YesNo

Do you have reduced function of the adrenal glands?
YesNo

Do you understand that acetazolamide is not licenced for acclimatisation but is supplied under official recommendations?
YesNo

Do you have any breathing or lung problems?
YesNo
If yes, please provide details:

Do you have any of the following conditions?
Pulmonary obstructionEmphysemaDiabetes mellitusImpaired alveolar ventilation

Have you been diagnosed with any of the following?
Suprarenal gland failureHypokalaemiaHyponatremiaAdrenocortical insufficiencyAddison’s disease

Do you have high chlorine blood levels or hyperchloremic acidosis?
YesNo

Do you have decreased sodium and/or potassium blood levels?
YesNo

Are you pregnant, planning pregnancy, or possibly pregnant?
YesNo

Are you breast-feeding?
YesNo

Do you have any liver problems?
YesNo
If yes, please provide details:

Do you have any current or past history of depression, anxiety, or psychiatric disorders?
YesNo
If yes, please provide details:

Are you a frequent traveller?
YesNo

Are you aware of how to reduce the symptoms of altitude sickness?
YesNo

Do you have any recent or past medical history of note?
YesNo
If yes, please provide details:

Please list all your current prescription medications including any over-the-counter items:

What location are you travelling to that requires altitude sickness medication?

Do we have permission to access your medical records?
YesNo