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Customer Medical Questionnaire – Thrush Treatment

Please answer every question so we can check this treatment is suitable. Your answers are used only to decide whether the medicine can be supplied, are reviewed by a pharmacist where needed, and are deleted after a fixed retention period.

eBay order number

*

1. Who is the treatment for?

*

A

Myself

B

Someone else

2. Age of the person needing treatment

*

A

16–60

B

Under 16

C

Over 60

3. Have you been diagnosed with thrush before?

*

A

Yes

B

No / First episode

4. How many times has thrush occurred in the last 6 months?

*

A

0–2

B

3 or more

5. Are you pregnant or breastfeeding?

*

A

No

B

Yes

6. Are you taking any of the following medicines?

*

Select all that apply.

Warfarin

Statins (simvastatin/atorvastatin)

Erythromycin

Diabetes medication (sulfonylureas)

None of the above

7. Do you have any liver problems, or have you been told to avoid fluconazole before?

*

A

No

B

Yes

8. Which symptoms are present?

*

Select all that apply.

Itching

Soreness

White discharge (non-smelling)

External irritation

Other symptoms

9. Do any of the following apply?

*

Select all that apply.

Abdominal or pelvic pain

Fever

Bleeding

Foul-smelling discharge

Pain during intercourse

Symptoms after STI risk

None of the above

10. Do you agree to read the Patient Information Leaflet and use the medicine as directed?

*

A

Yes

B

No

Use of your answers

*

I agree to my answers being used to decide whether this medicine can be supplied and being reviewed by a pharmacist.

I agree