Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.About You - Step 1 of 4Name *FirstLastEmail *Contact Number * *MaleFemaleDate of birth *Please provide your weight *KgStone/PoundsLayoutDropdown *Stones07 st08 st9 st10 st11 st12 st13 st14 st15 st16 st17 st18 st19 st20 st21 st22 st23 st24 st25 st26 st27 st28 st29 st30 st31 st32 st33 st34 st35 st36 stDropdown *Weight (Kg)404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100101102103104105106107108109110111112113114115116117118119120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200201202203204205206207208209210211212213214215216217218219220221222223224225226227228229230231232233234235236237238239240241242243244245246247248249250Dropdown *Pounds00 lb01 lb2 lb3 lb4 lb5 lb6 lb7 lb8 lb9 lb10 lb11 lb12 lb13 lbPlease provide your height *Feet & InchesCentimetresLayoutDropdownFeet04 ft05 ft06 ft07 ftDropdown *Centimetres120121122123124125126127128129130131132133134135136137138139140141142143144145146147148149150151152153154155156157158159160161162163164165166167168169170171172173174175176177178179180181182183184185186187188189190191192193194195196197198199200DropdownInches00 in01 in02 in03 in04 in05 in06 in07 in08 in09 in10 in11 inDo you smoke or drink? *YesNoPlease provide details (i.e. How much do you smoke or drink?) *Do you take any of the following medications? (Please select all that apply) *Isosorbide mononitrate/dinitrateNicorandilGlyceryl Trinitrate spray/tabletsAny other nitrate containing medication?Saquinavir/ritonavirHIV treatmentsItraconazole/Ketoconazole/ErythromycinNoneDo you take any medication whether prescribed, over the counter, herbal/alternative or partake in any recreational drug use? *YesNoPlease provide details *Do you have any allergies? *YesNoPlease provide details *What is your blood pressure? *Normal (90/60mmHg to 140/90mmHgHigh (over 140/90mmHg)Low (below 90/60mmHg)Not sureHave you been advised to avoid strenuous exercise? *YesNoPlease provide details *Are you able to walk 3 miles or climb a set of stairs without pain in your chest? *YesNoPlease provide details *Do you have any history of symptoms of anxiety or depression? *YesNoPlease provide detailsNextHave you been diagnosed by your GP as having hay fever/allergic rhinitis? *YesNoHave you used any Hay Fever or Allergy medication before? *YesNoPlease provide further details *Are you currently suffering from symptoms of hay fever? *YesNoWhich of the following symptoms do you usually experience? *Itchy NoseRunny Nose (clear discharge)Nasal CongestionPost Nasal DripSneezingCoughingItchy ThroatItchy EyesRunny eyes (teary)Sore eyesHives/skin reactionsOtherSelect the best description of your symptoms *Seasonal- Symptoms occur at roughly the same time each year in response to seasonal allergens (i.e. symptoms caused by pollens) such as hay feverPerennial - Symptoms occur throughout the year (most often caused by allergens from dust mites and pet dander/hair)Intermittent - Symptoms occur for less than 4 days per week or for less than 4 consecutive weeks (most often caused by a specific allergen you may come into contact with)Persistent - Symptoms occur for more than 4 days per week and for more than 4 consecutive weeks.What causes your symptoms? *PollenMouldsDust MitesOccupation relatedPet/Animal dander/hairOtherb. Are you pregnant or breastfeeding? *YesNoPlease provide details (copy) *Do you understand that should you experience any of the following symptoms you should **stop taking this medication and seek urgent medical attention** *YesNoSwollen face, tongue, or throat Difficulty swallowing Difficulty breathing Wheezing or shortness of breath Hives Are you aware that: *YesNoYou can visit Allergy UK or the NHS website to find out more about hay fever and allergic rhinitis. You can irrigate your nasal passages with saline as a non-medicated alternative. This can help wash allergens away from the sinus passages. Avoiding allergens is the best way to reduce your risk of getting hay fever symptoms. Showering and washing hair after pollen exposure and keeping windows shut can help to reduce exposure to air-borne allergens and pollens. Some medications (including 'non-drowsy' antihistamines such as fexofenadine) can still cause drowsiness in some individuals. It is your responsibility to ensure any medication you take does not adversely affect your ability to drive or operate machinery. If there is no improvement or any worsening of symptoms you should seek further help/support from either Quick Meds or your GP.NextWould you like us to inform your GP of your treatment? *YesNoWe recommend informing your GP surgery of any treatment that you are taking to keep your medical records relevant and up to dateDo you give us consent to write to your GP for approval of this supply and to share information we hold about you?NextDo you agree to the following? *YesNoYou have answered all of the above questions accurately and truthfully. You understand our prescriber(s) will prescribe medication based on your responses and interactions with Twilight Pharmacy. Any incorrect responses or deliberate acts to misinform may be hazardous to your health. You agree to the terms and conditions, privacy policy, and terms of use. You will familiarize yourself with the patient information leaflet included with your order and any other information relayed to you via other means including IM/E-mail/telephone. You will contact us and inform your GP if you experience any side effects to treatment, if there are any changes to your medical history including starting any new medications or new diagnoses, or if your symptoms/medical conditions change in any way. You understand completing a purchase does not guarantee supply of treatment; the final decision to prescribe lies with the prescriber with your best interests, health, and appropriateness in mind. You agree to the terms and conditions, privacy policy, and terms of use.Submit
