Consultation

Do you smoke or drink?

YesNo

Do you take any of the following medications?
(Please select all that apply.)

Isosorbide mononitrate/dinitrate Nicorandil Glyceryl Trinitrate spray/tablets Any other nitrate containing medication? Saquinavir/ritonavir HIV treatments Itraconazole/Ketoconazole/Erythromycin None

Do you take any medication whether prescribed, over the counter, herbal/alternative or partake in any recreational drug use?

Yes No

Do you have any allergies?

Yes No

What is your blood pressure?

Normal (90/60mmHg to 140/90mmHg) High (over 140/90mmHg) Low (below 90/60mmHg) Not sure

Have you been advised to avoid strenuous exercise?

Yes No

Are you able to walk 3 miles or climb a set of stairs without pain in your chest?

Yes No

Do you have any history of symptoms of anxiety or depression?

Yes No

Do you agree to the following?

• You have answered all of the above questions accurately and truthfully. You understand our prescriber(s) will prescribe medication based on your responses and interactions with Quick Meds. Any incorrect responses or deliberate acts to misinform may be hazardous to your health.
• You agree to the terms and conditions, privacy policy and terms of use.
• You will familiarise yourself with the patient information leaflet included with your order and any other information relayed to you via other means including IM/E-mail/telephone.
• You will contact us and inform your GP if you experience any side effects to treatment, if there are any changes to your medical history including starting any new medications or new diagnoses, or if your symptoms/medical conditions change in any way.
• You understand completing a purchase does not guarantee supply of treatment; the final decision to prescribe lies with the prescriber with your best interests, health and appropriateness in mind.
• You agree to the terms and conditions, privacy policy and terms of use.

Yes No