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07425 899611

Situational Anxiety Consultation

Situational anxiety, also known as state anxiety, is a type of anxiety that is triggered by specific situations or events. It is a normal and common human experience, as most people will feel anxious or stressed in certain situations, particularly when they perceive a threat or are facing a challenging or unfamiliar circumstance. Situational anxiety can manifest in various ways and can range from mild to severe.

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 seeking treatment for occasional (situational) anxiety?

Please Note: This means your anxiety only occurs in certain situations, such as exams or work meetings

Yes

No

Are you experiencing anxiety on a regular basis, or outside of specific anxiety-inducing situations?

Yes

No

Do you have any other mental health conditions? Please let us know, regardless of whether you're receiving treatment. This includes eating disorders, low mood, depression, schizophrenia, OCD, paranoia, and psychosis.

Yes

No

Are you allergic or sensitive to lactose?

Yes

No

Are you pregnant or breastfeeding?

Yes

No

Have you ever had a hypersensitivity or allergic reaction to propranolol, or any other beta blockers?

Yes

No

Have you ever been advised not to take beta blockers or propranolol?

Yes

No

Do you have, or have you ever had, asthma, obstructive airways disease, wheezing or bronchospasm?

Yes

No

Do you have any of the following conditions?

Diabetes
Liver disease
Kidney disease
Hypoglycaemia (low blood sugar)
Phaeochromocytoma

Yes

No

Do you have anorexia nervosa or are you underweight?

Yes

No

Do you have any heart or circulatory problems?

This includes:

Heart failure
Left Ventricular Dysfunction
A history of heart attack / myocardial infarction
Angina
Bradycardia
Cardiogenic Shock
Hypotension
Heart Block
Arrhythmias
Sick Sinus Syndrome
Peripheral Vascular Disease
Intermittant Claudication

Yes

No

Do you have high blood pressure or hypertension?

Yes

No

Are you taking any of the following medication?

Verapamil
Diltiazem
Rizatriptan
Any inhalers
Any medication for blood pressure
Warfarin
Digoxin
Disopyramide
Amiodarone
Calcium Channel Blockers
Beta Blockers
Ergotamine or dihydroergotamine
Chlorpromazine
Quinidine
Propafenone
Rifampicin
Theophylline
Thioridazine

Yes

No

I understand Profarma Direct is able to prescribe propranolol for situational anxiety only.

Yes

No

I understand I should not take this medication after a prolonged period of not eating or drinking.

Yes

No

I should not take this medication in the 48 hours prior to going under general anaesthetic.

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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How to check GPhC Registration

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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