About your Condition
We need to understand more about your specific condition to help find the most suitable medication or advice to help you. Please can you answer the following questions. If you get stuck or need any help, you can contact us.
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Why are you requesting treatment today?
How long have you been smoking?
How many cigarettes do you smoke per day? (on average)
How long after waking up (on average) would you have your first cigarette?
Have you ever previously tried to quit smoking?
Have you ever previously tried a treatment to stop smoking?
Have you ever previously experienced any of the following?
- Any kidney issues including decline in kidney function
- A history of any heart conditions- this includes any previous heart attacks, strokes, high blood pressure or any heart rhythm conditions
- Any history of seizures or epilepsy
- Any mental health issues- even if stable on treatment (e.g. depression, anxiety, Bipolar, schizophrenia)
- Any alcohol or drug dependency
Have you ever previously been diagnosed with any other medical conditions?
This includes conditions such as
- Asthma
- Kidney disease
- Liver disease
- Eczema
Do you suffer with any allergies?
Do you currently take any medication? This includes herbal remedies and over the counter medication.
Are you pregnant, planning a pregnancy or breast-feeding at the moment?
Is there any other information you would like to share with our prescribing team?
If so, please provide more information
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