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
Do you understand that this service is not suitable for treating emergency asthma or COPD symptoms?
If you are struggling with your breathing, having an asthma attack or have any chest pains or discomfort call 999 and go to A+E
Are you aware that the following symptoms require urgent medical treatment:
Do you suffer from Asthma or COPD?
Has your Asthma or COPD been diagnosed by a doctor?
Please explain why you are requesting this treatment
How long have you suffered from Asthma/COPD?
When was the last time you had an asthma/COPD review at your GP surgery?
Please provide the month and the year.
Are you currently using a reliever inhaler? (blue inhaler/ventolin/salbutamol/bricanyl)
Why are you not using a reliever inhaler?
Which reliever inhaler are you using?
How many times per week are you using your reliever inhaler?
Are you currently using a preventer inhaler? (e.g brown inhaler/clenil/fostair/seretide)
Why are you not using a preventer inhaler?
Which preventer inhaler are you using?
How many times per day are you using your preventer inhaler?
Have you been given inhalers within the last 2 months?
Including those prescribed by your GP, hospital, online or any other healthcare service provider.
Why are you requesting inhalers today?
Over the past month, how many times have you been short of breath?
Over the past month, did your asthma/COPD affect you being able to achieve what you wanted to?
This can be in work, outside of work or at home.
Over the past month, how many times did your asthma/COPD symptoms get you up at night?
The symptoms can include wheezing, shortness of breath, coughing and chest tightness.
Over the past month, please tell us how controlled your asthma/COPD has been?
Have you been to the hospital because of your condition in the last 12 months?
Please provide details
Are you aware that you should attend a review for your condition with your GP/Nurse every 12 months?
Are you confident with the use of the inhaler you have requested today?
Rapidly improve your inhaler technique. Click here to watch short videos on how to effectively manage your respiratory health condition symptoms and how to use your inhaler correctly.
Consent
Are you currently registered with a GP Practice?
Can you confirm why you are not currently registered with a GP below.
Please remember you must make sure to provide GP details next time, if you require a further repeat supply. Otherwise, we will not be able to accept any future inhaler requests.
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:
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