Pharmacy Assessment (Pain Relief)

1. Hi. Who is the medication for?

Myself

Someone else

My child

1b. Please provide the patient's details, including their age and relationship to you (if not for yourself):

2. What are the symptoms you're experiencing / why do you wish to purchase this treatment?

3. How long have you experienced these symptoms for?

4. Have you tried any medication, or lifestyle changes already to help with the symptoms?

Yes No

4b. Please provide details of what you have tried and whether they helped with your symptoms:

5. Have your symptoms worsened or changed recently, or all of the sudden?

Yes No

5b. Please provide more details:

6. Are you allergic to any medication or food (e.g. soya, nuts)? Or have any dietary restrictions?

Yes No

6b. Please tell us more about your allergies:

7. Have you ever had an adverse reaction to any NSAIDs (e.g. ibuprofen, aspirin, diclofenac) in the past?

Yes No

7b. Please provide details:

8. Are you on any other medication(s) (this includes other over the counter, herbal, prescribed, or illicit drugs)?

Yes No

8b. Please let us know the name of your medications:

9. Have you been diagnosed with any other medical condition(s) or had any recent surgery (including for cancer)?

Yes No

9b. Please provide more details:

10. If you are female, can you please confirm if you are pregnant or breastfeeding?

Yes No

11. 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.
You will contact your GP if your symptoms worsen or don’t improve after using this treatment for the recommended duration.
You have answered the questions honestly and accurately.
You will read and understand the patient information leaflet supplied with your medication.
You understand that supply decisions will be based on the answers to your consultations, 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.

Yes No

11b. We cannot supply you with this treatment at the moment. Please contact our patient support team at enqiuries@thefamilychemist.co.uk so we can talk through your options.

Yes No

Cancel

Name	Purpose	Expiry
CFID	This is a session cookie and is necessary for the operation of the site.	1 day
CFTOKEN	This is a session cookie and is necessary for the operation of the site.	1 day
SBCOOKIECONSENT	This cookie allows us to remember what choices you made relating to cookies you want to use on this site	1 year

Name	Purpose	Expiry
__UTMA	Used to distinguish users and sessions. The cookie is created when the javascript library executes and no existing __utma cookies exists. The cookie is updated every time data is sent to Google Analytics.	2 years from set
__UTMB	Used to determine new sessions/visits. The cookie is created when the javascript library executes and no existing __utmb cookies exists. The cookie is updated every time data is sent to Google Analytics.	30 mins from set
__UTMC	Set for interoperability with urchin.js. Historically, this cookie operated in conjunction with the __utmb cookie to determine whether the user was in a new session/visit.	When browser closed
__UTMT	Used to throttle request rate, used by Google Analytics	10 minutes
__UTMV	Used to store visitor-level custom variable data. This cookie is created when a developer uses the _setCustomVar method with a visitor level custom variable. This cookie was also used for the deprecated _setVar method. The cookie is updated every time data is sent to Google Analytics.	2 years from set
__UTMZ	Stores the traffic source or campaign that explains how the user reached your site. The cookie is created when the javascript library executes and is updated every time data is sent to Google Analytics.	6 months from set

Pharmacy Assessment (Pain Relief)

Opening times

Today’s Responsible Pharmacist

Sign In