Your Health
The information you provide us is treated with absolute confidentiality and will be reviewed by our experienced UK prescribers. We ask the following questions to provide the prescriber with an appropriate level of information to make an informed decision on whether the treatment is suitable or not.
What is your gender?
Please provide more detail.
Do you need help completing this questionnaire?
Please contact us on 020 7157 9759 or email [email protected] and we can assist you.
Do you believe that you have the capacity to make decisions about your own healthcare?
Sorry we can't offer you this treatment, please contact your GP.
Have you been diagnosed with any medical conditions?
Are you currently taking any medication? This includes prescription-only, over-the-counter and homeopathic medicines.
Do you suffer from any allergies?
Please provide details including which allergies and what symptoms you experience.
Is there anything else you would like to include to allow our prescriber to prescribe responsibly?
Medical Questions
Have you been diagnosed with IBS by your doctor?
Are you suffering from stomach cramps?
Are you experiencing constipation?
Are you experiencing diarrhoea?
Are you experiencing excessive wind?
Are you suffering from bloating?
Are your symptoms relieved by passing stool?
Do you experience altered stool passage? (straining, urgency or unable to pass a full stool)
Do you experience bloating or abdominal distension/hardness?
Are your symptoms often made worse by eating?
Do you experience the passing of mucus when passing a stool?
How long have you suffered from these symptoms?
Have you experienced blood passing in your stools?
Please provide more information
Have you unintentionally lost weight or have your regular IBS symptoms changed recently?
Are you buying more than one of this treatment?
Please tell us why
Is there anything that noticably causes your symptoms or makes them worse?
Consent
Would you like us to notify your GP of the treatment you chose to order today?
Please provide details.
It is very important that your GP is aware of all the medication you are taking, so that you are receiving the best possible care. You should only select “no” if you are completely sure you do not wish us to tell your GP.
Do you agree to the following:
If treatment is not suitable, you will be fully refunded and signposted to another point of care. The decision about the treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.
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