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Ibuprofen Pain Relief – Mandatory Health Screening

Please answer every question so we can check this medicine 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

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1. Who is the medicine for?

*

A

Myself

B

Someone else

2. Age of the person requiring treatment

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A

12 or older

B

Under 12

3. What type of pain are you treating?

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A

Headache / migraine

B

Toothache

C

Period pain

D

Back or muscular pain

E

Fever

F

Other

4. Does the person have any of the following?

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Select all that apply.

Stomach ulcer or bleeding history

Asthma triggered by NSAIDs

Kidney disease

Heart failure

Liver disease

None of the above

5. Is the person pregnant or breastfeeding?

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A

No

B

Yes

6. Is the person allergic to ibuprofen, aspirin, or other NSAIDs?

*

A

No

B

Yes

7. Is the person taking any of the following medicines?

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Select all that apply.

Warfarin or other blood thinners

Other NSAIDs (naproxen, diclofenac)

Steroids

Lithium

Methotrexate

Blood pressure medicines (ACE inhibitors/ARBs)

None of the above

8. Is the pain severe, unusual, or lasting longer than 10 days?

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A

No

B

Yes / unsure

9. Do you agree to read the Patient Information Leaflet and use the lowest effective dose?

*

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