Are you purchasing this medication for yourself?
Are you over 18?
Do you currently smoke?
Please enter the date you stopped smoking
DD/MM/YYYY
Please enter the date you will stop smoking
You should start medication before your planned quit date.
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Are you pregnant, trying to become pregnant or breastfeeding?
Do you currently, or have a previous history of any psychiatric illness such as schizophrenia, bipolar disorder, depression, anxiety, panic attacks or ADHD?
Do you have a history of epilepsy, seizures, a condition that lowers the seizure threshold or ever had a serious brain injury?
Have you been previously diagnosed with moderate or severe kidney disease, impairment or told your eGFR < 30mL/minute/1.73m2
Do you suffer or have you ever suffered from cardiovascular disease including but not limited to coronary heart disease, angina, myocardial infarction (heart attack), heart failure, stroke, transient ischaemic attack (TIA), peripheral arterial disease, aortic disease, arrhythmias such as atrial fibrillation, deep vein thrombosis, pulmonary embolism or congenital heart disease?
Do you take any of the following medication: aminophylline, theophylline, chlorpromazine, clozapine, erlotinib, flecainide, methadone, olanzapine, riociguat, warfarin?
Do you take any other medication or have any other medical conditions?
Please specify any medication you are taking, or medical conditions you have
Do you have any allergies?
Please specify any allergies
I will read the patient information leaflet before using any provided treatments.
I agree that
I understand that Menschem will not inform my GP of this consultation, unless specifically requested via emailing info@menschem.co.uk (please include GP name, address, and email address).
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