To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

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If yes, please describe the product/reaction.




If yes, please provide details

Please provide details in this box here...

If yes, please provide details


Significant unintentional weight loss / Recurrent vomiting / Dysphagia (swallowing problems) / Haematemesis (vomiting food or blood, which may appear as dark coffee grounds in your vomit) / Melaena (blood stained faeces)

E.g. fructose intolerance, glucose-galactose malabsorption, or sucrase-isomaltase insufficiency


If yes, please provide details


If yes, please provide details

Cough or hiccups that keep coming back / A hoarse voice / Bad breath / Bloating and feeling sick









Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.

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- You declare that I have answered the above truthfully- You will read the patient information leaflet before taking your medication (if prescribed)- You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment- You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health- You understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor