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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This refers to your biological gender
Male
Female

Height should be above 1 ft 10 inches

Use the following as a guide:Low = Under 90/60Normal = Between 90/60 and 140/90High = Over 140/90

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

If so, please tell us how many units per day. You can use the following as a guide:- Pint of beer = 3 units- A can of beer = 2 units- A large glass of red wine = 3 units

If you cannot, please provide more information


If you do, kindly explain them below

Please list all your current prescription medication including any medication you buy over the counter.


If so, please provide more information

If so, please provide more details



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 you are male, answer No

If you are male, answer No


If yes, please provide more details 



If yes, please provide details














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


Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.