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info@profarmadirect.com
07425 899611

Acid Reflux Consultation

Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat (acid reflux). If it keeps happening, it's called gastro-oesophageal reflux disease (GORD).

1. About your Health

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Please state your gender

This refers to your biological gender

Male

Female

What is your date of birth?

Use the calendar to select your date of birth.

Please add your height (in cms)

Your height is important for the prescribers decision.

Please add your current weight (in kgs)

Please make sure to add your current weight. This may affect the prescriber's decision.

Do you have any recent or past medical history of note?

If so, please provide more information

Yes

No

Do you suffer from any allergies?

If so, please provide more information

Yes

No

Do you currently take any medication whatsoever?

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

Yes

No

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

No

Are there any other health/medical details you feel we should know?

If so, please provide more information

Yes

No

2. About your Condition

To help us understand that this treatment is the right option for you, please answer the following questions.

0%

Is this a repeat prescription?

Yes

No

Are you experiencing acid reflux at least twice a week? Symptoms include:

Heartburn - a burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours
Chest pain, especially after bending over, lying down or eating
Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat
Feeling of food "sticking" in the middle of the chest or throat

Yes

No

Are you experiencing any of the following?

difficulty swallowing
unintentional weight loss
abdominal swelling
persistent vomiting
severe/persistent diarrhoea
vomiting blood
blood in your stools or black, tarry stools
have iron deficiency anaemia
severe liver problems

Yes

No

Do you have an allergy (hypersensitivity) to medicines containing proton pump inhibitors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?

Yes

No

Are you breast feeding or pregnant or possibly pregnant?

Yes

No

Do you have any of the following conditions:

Osteoporosis
Liver problems
Gastric cancer
Hypomagnesaemia (low magnesium in the blood)

Yes

No

Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor?

Yes

No

Are you taking any of the following medications?

NSAID anti-inflammatory painkillers (e.g. ibuprofen)
Ketoconazole, itraconazole, posaconazole or voriconazole (used to treat infections caused by a fungus)
Digoxin (used to treat heart problems)
Diazepam (used to treat anxiety, relax muscles or in epilepsy)
Ulipristal (used as emergency contraception or treatment for fibroids)
Phenytoin or Fosphenytoin (used in epilepsy)
Medicines that are used to thin your blood, such as warfarin or other vitamin K blockers.
Rifampicin (used to treat tuberculosis)
Atazanavir, Rilpivirine, Tripranavir, Saquinavir, Nelfinavir, Raltegravir (used to treat HIV infection)
Ledipasvir (used for Hepatitis C treatment)
Ciclosporin or Tacrolimus (in cases of organ transplantation)
St John's wort (Hypericum perforatum) (used to treat mild depression)
Cilostazol (used to treat intermittent claudication)
Clopidogrel (used to prevent blood clots (thrombi))
Vitamin B12, Cyanocobalamin, Hydroxocobalamin
Erlotinib, Dabrafenib, Lapatinib or Pazopanib (for cancer treatment)
Clarithromycin (an antibiotic)
Methotrexate (for cancer or rheumatoid arthritis treatment)
Escitalopram (an antidepressant)
Clozapine (for schizophrenia)

Yes

No

Do you understand that healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable?

Yes

No

Do you understand that acid reflux treatment supplied through this service can only be used for the short-treatment of gastroesophageal reflux disease (GORD) also known as heartburn/acid indigestion for a maximum of 28 days?

Yes

No

Do you understand that if you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment?

Yes

No

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

No

3. The Agreement and Consent

Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

0%

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes

No

I agree to the Terms and Conditions and I confirm that I am over 18.
Terms and Conditions

Yes

No

About Us

Profarma Direct is a cutting-edge online pharmacy that specialises in lifestyle medicine and personalised prescriptions.

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom
07425 899611
For Sales & Orders:
info@profarmadirect.com
For General Enquiry:
info@profarmadirect.com

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You can check our pharmacy details and registration status here. You can also see details of any Fitness to Practise decisions relating to a registrant.

GPhC Registration Number:

2076639

GPhC Registered Owner:

Profarma Direct Ltd

Superintendent Pharmacist:

Zakaria Jalgaonkar

GPhC Pharmacy Details:

Marsh House Lane, Darwen, Lancashire, BB3 3JB, United Kingdom

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