Gout | Profarma Direct

1. About your Health

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

Do you have any problems with your stomach or gut (intestine), such as an ulcer or bleeding?

Yes

Do you have any autoimmune condition such as systemic lupus erythematosus?

Yes

Do you have a history of gastrointestinal diseases such as ulcerative colitis or Crohn's disease?

Yes

Did you get diagnosed with Gout after a blood test revealed high uric acid levels?
If so, have you had a blood test to examine the functionality of your kidney?

If not, how do you know if you have gout?

Yes

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

Yes

Are you aware of any malfunctions in your liver or kidney?

Yes

Where do you intend to use this product?
It could be on your shoewear, feet etc

Have you started any new medication since your last order?

Yes

Do you know how to how to use Daktarin powder?
Before applying the product, your feet should be thoroughly cleaned and dried especially the toes
The powder is to be applied on the affected and surrounding area
The powder is mainly used twice a day
You can dust the powder on places that are in contact with the affected part such as your socks, or shoes
After using the powder, you must wash your hands thoroughly with soap and clean water
Even after the infection has cleared, you must continue applying the powder for atleast ten days

Yes

Kindly share your weight and height
Height should be above 1 ft 10 inches

Does any of these describe you?
You have an underlying medical condition
You've been through a major surgical procedure
You have allergic reactions
You have cardiovascular conditions or might have had suffered a stroke
You suffer from a low liver or kidney function

Yes

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Do you take at over 10 alcoholic drinks in a week?
A single alcoholic drink equals: A pint of 4% alcoholic bevarages, 175 ml (medium) wine glass, Twice the level of spirit

Yes

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you a smoker?

Yes

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Can you relate to any of the following statements:
Colchicine is a drug to which you are allergic or hypersensitive.
You've previously used colchicine and experienced major adverse effects.
Colchicine is being used to treat a condition other than severe gout.

Yes

Are you aware of how high or low your blood pressure is?
This could be from an examination by your doctor, a certified medical practitioner or self-examination.

Yes

Have you previously had a transient ischaemic attack (mini stroke) or stroke?

Yes

Did you know that you should immediately stop using the medication and seek emergency medical treatment once you experience the following symptoms?
High fever
Mouth-ache and sores
Throat irritation
Long-term bleeding
Bruises
Rashes on the skin
Vomiting or nausea
Pain in the abdomen
Diarrhoea that persists after you stop taking the treatment
When having a bowel movement, you may experience pain or bleeding

Yes

Do you have a history of using Glyceryl trinitrate spray?
If not, where do you intend to use this medication?

Yes

Do you suffer from any allergies?
If you do, kindly explain them below

Yes

Do you have a blood condition diagnosis?

Yes

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

Do you use any of the medications listed below?
Blood-thinning medications (such as warfarin).
Acarbose is a kind of sugar (to treat diabetes).
Ciclosporin is a kind of antibiotic (to prevent organ rejection).
Lithium is a kind of lithium (for mental health problems).
Amiodarone is a kind of amiodarone that is (for heart problems).
Medicines for the treatment of epilepsy and seizures.
Antiretroviral drugs (ARVs) are drugs that are used to treat HIV
Medicines for the treatment of psychosis and other mental illnesses.

Yes

Have you recently undergone major surgery or major trauma?

Yes

Do you have a history of using colchicine?

Yes

Since when has the intended user experience these symptoms?
Please select your option

At least 72 hours

A week

A month

More than a month

Has a certified medic diagnosed you with rheumatoid arthritis?

Yes

Has a certified medical practitioner diagnosed you with a heart disease?
If not, where do you intend to use this medication?

Yes

Are you having a fever or a temperature that is higher than 38°C?
If so, could youprovide us with more details about how you're feeling right now?

Yes

Do you presently have any medications for your gout attack? It could be pain relievers?
If so, what medications are you taking?

Yes

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

Do you know how to how to use Lamisil AT 1% Gel?
Before applying the product, your feet should be thoroughly cleaned and dried
The cream is to be applied on the affected and surrounding area
The cream should be applied once a day for a week
Treatment should be used for atleast a month
After applying the cream, you must wash your hands thoroughly with soap and clean water
You must seek further medical assistance if you have not noticed any improvements after using the cream for a fortnight

Yes

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

Yes

Are the symptoms of your current gout attack the same as they were during past attacks?
If not, could you please provide more information on how different the symptoms are?

Yes

If you've experienced this problem before, did it go away on its own with painkillers?
If not, what treatment did you utilize that was effective?

Yes

Have you tried to manage your weight by altering your diet and increasing physical activity?

Yes

Are you suffering from a gout attack right now?
If you answered 'No,' are you optimistic about your ability to recognize gout attacks when they occur?

Yes

Do you have a medical history of any of the following listed below?
Diabetic gastroparesis; Inflammatory bowel disease; Ketoacidosis; Congestive heart failure; Severe renal impairment; Severe hepatic impairment; Thyroid disease; Pancreatitis.

Yes

2. About your Arthritis or Gout

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

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

Is this medication for yourself?
If this is not for yourself, please can you tell us who it is for and their age. e.g. grandmother (79yrs old)

Yes

Are you suffering symptoms?
If so, please describe the symptoms for us

Yes

How long have the symptoms been present?
Please specify the numnber of days/weeks

Do you experience any of the following?
You are under medication or receiving supplements
You have a medical condition
You are currently breastfeeding or pregnant

Yes

Have you tried any other medicines to treat the condition already?
If so, please provide more information.

Yes

Do you recognize that this medication should not substitute further treatment incase of an emergency?
Incase you experience an asthma attack, have difficulties in breathing or discomfort in the chest, be sure to seek emerency treatment

Yes

Did you know the following symptoms warrant for immediate medical care?
Your inhaler no longer eases up any symptoms
There seems to be an urgency for you to keep on using your inhaler
Increased caughs, wheezing, chest discomfort and tightness
Loss of breath when eating, sleeping or speaking
Increased heart beat
Breathing rapidly
Feeling weak, drowsy, dizzy or exhaustion
Change in color on certain body parts such as fingers and mouth to blue

Yes

Has a qualified medical practitioner examined your asthmatic condition?
Please reach out if you need further assistance comprehending this question

Yes

When did your last undertake an Asthma review from a certified medical practitioner?
please provide the specific month and year

In the past month, how often have you experienced a shortness in breath?
Please select your option

Everytime

Frequently

Occasionally

Seldom

Never

Are you suffering from any side effects from this medication?
You can find out the side effects of your medicine here.

Yes

How frequently did you experience asthmatic symptoms at night in the past month?
The symptoms include shortness of breath, Coughing, wheezing, chest pains

Everytime

Frequently

Occasionally

Seldom

Never

Have you received advice from a weight management counsellor before?

Yes

In the course of the past month, how many times have you used your inhaler reliever?
Please select your option

Not once

Approximately twice a week

More than thrice a week

Once a day

More than once a day

Women only: are you currently breast-feeding?

Yes

Over the last five years, have you been admitted to hospital over your asthma condition?

Yes

Do you consent to do the following?
Only use your inhaler as prescribed by a certified doctor?
Consult with a certified medical practitioner when your condition changes
Undergo annual asthma reviews from your doctor

Yes

3. The Agreement and Consent

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

Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.

Yes

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