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Acid Reflux

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 enquiries@thefamilychemist.co.uk

About You

1. Are you purchasing this medication for yourself?
2. Are you over 18 years old?
3. Are you more than 55 years of age?
4. Are you breast feeding or pregnant or planning to become pregnant?

Medical History

5. Have you been diagnosed of acid reflux previously/currently?
6. Are you currently taking any acid reflux medication?

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

  • 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. Are you experiencing any of the following?

  • difficulty swallowing
  • unintentional weight loss
  • abdominal swelling
  • persistent vomiting
  • severe/persistent diarrhoea
  • vomiting/coughing up blood
  • blood in your stools or black, tarry stools
  • iron deficiency anaemia

Consult your GP urgently. These symptoms indicate the possibility of a more serious illness.

9. Do you have any of the following conditions:

  • Osteoporosis
  • Gastric cancer
  • Hypomagnesaemia (low magnesium in the blood)

Past Medical History

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

Please provide more details:

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

Please provide more details:

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

Please provide more details:

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

15. Do you agree with the following?

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

  • 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 for a maximum of 28 days
  • I will contact my GP if I experience no relief after 14 days or your symptoms persist after 28 days of treatment.
  • 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.

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

Please click "Yes".