Acid Reflux - WePrescribe

Heartburn and Acid Reflux Consultation

Are you a female?

What is your D.O.B (dd/mm/yyyy)

Are you looking to access treatment for yourself?

Have you previously been prescribed any medication for this condition by your GP or any other healthcare professional?

Please provide more details

Are you or have you experienced any of the following symptoms?

-Regular vomiting
-Coughing up blood
-Blood in your stools
-Feeling that food gets stuck after swallowing
-Darker coloured stools than normal
-Unexplained weight loss
-Difficulties swallowing

How long have you been experiencing symptoms of heartburn/indigestion?

Have you ever been diagnosed with any other medical conditions?

This can include:

-Immune system conditions such as HIV
-Liver or kidney issues

Please provide more details

Do you suffer with any allergies?

Please provide more details

Are you pregnant, planning a pregnancy or breast-feeding at the moment?

Do you currently take any medication? This includes herbal remedies and over the counter medication.

Please provide more details

Is there any other information you would like to share with our prescribing team?

Please provide more details

We strongly recommend that you inform your GP of any treatment you receive. Would you like WePrescribe to do this on your behalf?

I have read and understood the Terms and Conditions.

Acid Reflux Consultation

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