Your Cart
0115 8501944
Trustpilot
0115 8501944
0% Complete

Stop Smoking 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]

About You

1. Hi. What is your name?

2. Are you purchasing this medication for yourself?

2b. Who is this medication for? Please provide full name, date of birth and registered address of the patient.

3. Are you over 18 years old?

STOP: You can not use The Family Chemist. Please see your GP.

4. Are you breast feeding, pregnant or planning to become pregnant?

4b. Please tell us whether your are breastfeeding OR if you are pregnant: please tell us how many weeks pregnant you are

5. Do you currently smoke?

STOP: You cannot use Stop Smoking Treatments if you do not smoke.

6. Do you take any medication for, or have a history of any mental health condition?

6b. Please provide more details: Do you still take medication and if so what medication do you take?

7. Do you have a history of epilepsy, seizures or have a low seizure threshold?

7b. Please provide more details:

8. Have you tried Champix (Varencline)/ Zyban (bupropion) in the past to stop smoking?

8b. When did you use Champix/ Zyban? Did you ever experience side effects from Champix/ Zyban

9. What is your blood pressure?

10. Do you drink alcohol?

Using Zyban with excessive alcohol may increase the risk of uncommon side effects. On the other hand, sudden withdrawal from alcohol following regular or chronic use can also increase your risk of seizures during treatment with buPROPion

10b. Please enter what you drink and how much you drink in average over a week?

11. Do you have any dependency to benzodiazepines?

11b. Please provide me more details

12. Do you suffer from or ever suffered from any of the following?

  • Central nervous system tumour.
  • current or previous diagnosis of eating disorders like bulimia or anorexia nervosa.
  • severe hepatic cirrhosis
  • history of bipolar disorder
  • history of head trauma
  • diabetes treated with tablets or insulin
  • alcohol abuse
  • use off stimulants or anorectic products.

12b. Please provide more details:

13. Do you have any kidney or liver impairment?

13b. Please provide more details

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

14b. Please provide more details:

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

15b. Please provide more details:

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

16b. Please provide more details:

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

17b. Please provide more details:

Start Typing and your Practice will appear here
Unable to find your surgery? Click Here

18. 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.
  • I will stop treatment of Champix/ Zyban if I develop changes in behaviour or thinking, anxiety, psychosis, mood swings, aggressive behaviour, or depression, or if I develop suicidal thoughts or behaviours, I will inform my doctor immediately.
  • I will stop treatment with Champix/Zyban if I experience a seizure while on treatment.
  • I will monitor my blood pressure regularly whilst taking Zyban. I will stop taking Zyban and seek medical attention if my blood pressure raises higher than 150/90.
  • I will notify my doctor if I develop new or worsening cardiovascular symptoms and to seek immediate medical attention if I experience signs and symptoms of a heart attack or stroke.
  • 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.

19. I confirm that I have read the information in this questionnaire and will follow the advice from the patient information leaflet before using the provided treatments.