High Cholesterol Treatment Consultation

Personal Information

Please provide your details accurately

Name *

First

Last

Date of birth? *

YYYY

Phone number? *

Address? *

Email *

Which of the following medication you are looking to get prescription for? *

Are you have any side effects due to this medication or any reaction in the past? *

NO YES, I HAVE

If YES, I HAVE, please specify:

What dose you are currently taking of this medication? *

For how long you have been taking this medication? *

LESS THAN TWELVE WEEKS TWELVE WEEKS TO TWELVE MONTHS MORE THAN TWELVE MONTHS

Last time which healthcare professional prescribed you this medication? *

DOCTOR ONLINE DOCTOR CONSULTANT SPECIALIST OTHER

If OTHER, please specify:

Have you recently got your Liver function checked? If yes what was the result? *

YES - THE RESULT WAS NORMAL YES - THE RESULT WAS ABNORMAL NO - I NEVER HAD SUCH A BLOOD TEST

Have you discussed your current medications with your GP in last 12 months? *

NO YES, I HAVE

If YES, I HAVE, please specify the outcome of this review by your GP:

Do you have past medical history of any of the following condition? *

Select all that apply

A STROKE OR MINI-STROKE (TIA) ANGINA CHRONIC KIDNEY DISEASE DIABETES A PARENT, BROTHER OR SISTER WHO HAD A HEART ATTACK OR STROKE UNDER THE AGE OF 60 A HEART ATTACK PERIPHERAL VASCULAR DISEASE OTHER HEART PROBLEMS HIGH BLOOD PRESSURE TREATED WITH MEDICATION NONE OF THE ABOVE

If OTHER, please specify:

Health Information

Please provide details about your health

Please specify your gender? *

FEMALE MALE

Are you allergic to any medication or any substance? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Please specify your current weight? (In Kg)

Please specify your current height (In Cm)

Are you a smoker? *

Do you have any past medical history of liver or kidney disease? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Do you have any past medical or surgical history other than already above mentioned condition? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Are you on any regular medication? If yes please specify below.

In the past two months have you used any prescription, non-prescription, recreational/illegal drugs or herbal medications other than above mentioned medication? *

NO YES, I HAVE

If YES, I HAVE, please specify:

Please specify the name of preferred pharmacy where you want to collect your prescription/medications? *

I understand the above mentioned questions and I have answered them truthfully and to the best of my knowledge. *

I CONFIRM I DO NOT CONFIRM

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Consultation Summary

High Cholesterol Treatment Consultation Fee

GP Review + Prescription

€25.00

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