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Acid Reflux Assessment

To ensure you are provided with the most effective treatment by our healthcare professional please answer the questions honestly and accurately. The questionnaire should only take approximately 3 minutes to complete.

If you are unsure about any of the questions, please call us on 0115 8501944 or email us at [email protected]

1. Hi. What is your name?

2. Are you over 18 years old and purchasing this medication for yourself?

STOP! This consultation should only be filled in by the patient. We do not supply medication to patients under 18.

3. Are you breast feeding or pregnant or planning to become pregnant?

STOP! We cannot supply you with this medication. Please visit your GP.

4. Have you been diagnosed of acid reflux or heartburn from your doctor before?

Acid reflux symptoms should resolve within 5 days of treatment. If symptoms persist, schedule an appointment with your GP.

A confirmed diagnosis of acid reflux or heartburn requires an endoscopy procedure where a camera is passed through the mouth into the body.

5. Are you any of the following:

STOP! It is important that you see your doctor in person for a consultation. Unfortunately, we cannot provide medication.

Over 55 years old and suffering from new onset of symptoms.

Any age and any of the following: unintentional weight loss, anaemia, appetite loss,  unexplained upper abdominal lump, difficulty and/or painful swallowing, vomiting/ coughing up blood, persistent diarrhoea, black, shiny or bloody stools, previous stomach ulcers or surgery,

6. Are you currently taking any acid reflux medication?

6b. Please tell us the name, strength and dose of the medication you are taking? Has it worked for you?

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

STOP! You are not suffering from Acid Reflux. Please call The Family Chemist clinician for more help.

  • 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

8. Do you have or had any of the following conditions:

9. 10. Do you have any kidney or liver impairment?

9b. Please provide more details

10. Do you have any other medical conditions (e.g. cancer) or past surgical procedures (e.g. splenectomy)?

10b. Please provide more details

11. Are you currently taking or recently stopped taking any prescription medicines, over-the-counter medicines, herbal medicines or recreational drugs?

11b. Please provide more details:

12. Are you allergic to any medicines or other substances e.g. peanuts or soya?

12b. Please provide more details

13. Would you like us to pass on details of your treatment to your GP?

14. Do you agree with the following?

  • You have read the information available on the treatments and medication web page and understand the side effects, their effectiveness and alternatives available.
  • Acid reflux treatment supplied through this service can only be used for the short-term treatment of gastroesophageal reflux disease (GORD), also known as heartburn/acid indigestion.
  • You will contact my GP if I experience no relief after 14 days or if your symptoms persist after 28 days of treatment.
  • You will contact your GP if the symptoms change or worsen.
  • You have answered the questions honestly and accurately and the treatment is solely for your personal use.
  • You will read and understand the patient information leaflet supplied with your medication.
  • You understand that although it is not compulsory, it is important to inform your GP of this treatment so they can provide safe healthcare.
  • You understand prescribing decisions will be based on the answers from your consultation and incorrect information can cause harm to your health. Orders may be rejected if not clinically suitable.
  • You are aware The Family Chemist will undertake a soft check to validate your identity using LexisNexis. Note: This does not affect your credit rating.
  • You have read and agree to our Terms and Conditions, Terms of Use and Privacy Policy.

15. I confirm that I have read the information in this questionnaire and will follow the advice shown here and in the product leaflet