Anaphylaxis Treatment Consultation

Personal & Medical Information

Please provide your details accurately

Name *

First

Last

Date of birth? *

YYYY

Phone number? *

Address? *

Email? *

Please specify which of the following medication you are looking for? *

Why are you looking for the prescription of above medication? *

PREVIOUS PRESCRIPTION HAS EXPIRED PRESCRIPTION FOR AN ADDITIONAL PEN OTHER

If OTHER, please specify:

Which healthcare professional prescribed you this medication last time? *

DOCTOR ONLINE DOCTOR CONSULTANT SPECIALIST OTHER

If OTHER, please specify:

Have you discussed your medication with your doctor in the last 12 months? *

NO YES, I HAVE

If YES, I HAVE, please specify the outcome of this review by your GP:

Please specify if you have any of the following underlying conditions? *

Select all that apply:

A STROKE OR MINI-STROKE (TIA) ANGINA CHRONIC KIDNEY DISEASE DIABETES A PARENT, BROTHER OR SISTER WHO HAD A HEART ATTACK OR STROKE UNDER THE AGE OF 60 A HEART ATTACK PERIPHERAL VASCULAR DISEASE OTHER HEART PROBLEMS HIGH BLOOD PRESSURE TREATED WITH MEDICATION NONE OF THE ABOVE

If OTHER, please specify:

Has any healthcare professional diagnosed you with anaphylaxis? *

YES NO

Do you have any underlying liver or kidney disease? *

YES NO

Doctor365 will not be able to help you if you are currently having anaphylaxis reaction. Do you fully understand that? *

If No - having an anaphylactic reaction now, call 999 and explain your situation.

YES

Do you know how to use adrenaline auto injector or has any healthcare professional shown you how to use adrenaline auto injector correctly and safely? *

YES NO

Please specify if you are currently taking any of the following medications? *

Select all that apply:

NO Tricyclic antidepressants MAOIs Parkinson's treatments Digitalis Quinidine Medicines for heart disease Alpha blockers Beta blockers

If other, please specify:

Please specify if you are suffering from any of the following medical conditions? *

Select all that apply:

No Heart disease High blood pressure Overactive thyroid Diabetes Tumour on adrenal gland Glaucoma Reduced kidney function Prostate disease Low potassium levels in blood High calcium levels in blood Asthma

If other, please specify:

By proceeding with this consultation you agree that you will read the instructions in the information leaflet which comes with the medication and if you are not sure you will contact your GP for further instruction and information how to use it. Do you agree? *

YES I AGREE NO

Additional Details

Please provide additional information for our medical review

Are you allergic to any medication or any substance? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Are you a smoker? *

Do you have any past medical or surgical history that you want to inform our doctor? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Other than above mentioned regular medication, have you used any prescription, non prescription, illegal or herbal medication recently? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Please specify your gender? *

MALE FEMALE

Please specify the name of preferred pharmacy where you want to collect your prescription/medications. *

I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge. *

I CONFIRM I DO NOT CONFIRM

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Review your details and complete payment

Consultation Summary

Anaphylaxis Treatment Consultation Fee

GP Review + Prescription

€25.00

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