Acid Reflux Assessment Form – Workspace Tabi Health

Patient Name

First

Last

Parent or guardian name (if patient is under 16 years)

First

Last

Have you had a reaction to esomeprazole, rabeprazole sodium, lansoprazole or medicines containing other proton pump inhibitors?

Do you have any allergies?

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Are you breast feeding?

Do you have any liver or kidney problems?

Do you have any of the symptoms listed below?

Heartburn (burning sensation in the middle of your chest)
Acid regurgitation (a sour taste in your mouth)
None of the above

Have you had a stomach ulcer or stomach surgery in the past?

Do you have any new or recently changed reflux symptoms?

Have you had any of the symptoms listed below?

Significant unintentional weight loss
Recurrent vomiting
Dysphagia (swallowing problems)
Haematemesis (vomiting food or blood, which may appear as dark coffee grounds in your vomit)
Melaena (blood stained faeces)
None of the above

Have you had any of the symptoms listed below?

Do you need to take a non-prescription indigestion or heartburn remedy treatment every day?

Do you have any of the symptoms listed below?

Cough or hiccups that keep coming back
A hoarse voice ̵ Bad breath
̵Bloating and feeling sick
None of the above

Are you due to have an endoscopy, urea breath test or Chromogranin A blood test?

Have you been told by your doctor that you have an intolerance to any sugars?

Are you currently suffering from any infections, severe diarrhoea or persistent diarrhoea?

Do you have osteoporosis?

Do you have jaundice (yellowing of skin or eyes)?

Have you been told by your doctor that you have an intolerance to any sugars? E.g. fructose intolerance, glucose-galactose malabsorption or sucrase-isomaltase insufficiency

Assessment for proton pump inhibitors

Do you have inflammation in your oesophagus?

Do you have a magnesium deficiency?

Do you have a vitamin B12 deficiency

Assessment for Esomeprazole

Do you have any new or recently changed reflux symptoms?

Have you been taking treatment continuously for reflux or heartburn for 4 or more weeks?

Please list all your current prescription medication including any medication you buy over the counter e.g. Nelfinavir

Please provide details of any recent or past medical history of note

Complete Patient Details

Patients Name

First

Last

Date of Birth (DD/MM/YYYY)

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

GP Notification

Tick to confirm that you agree we share consultation with your GP.

Patient Consent

I agree that my Summary Care Records willl be accessed to confirm medication history with the GP.

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Patient Name

First

Last

Parent or guardian name if applicable

First

Last

Have you had a serious reaction to any acne treatments before?

Do you have any allergies?

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy)

Are you breast feeding?

Have you started puberty?

Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment?

Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea?

Are you currently using any other treatments for acne?

Have you recently received an acne treatment containing antibiotics?

If you have used acne treatments before, did you experience any side effects or skin irritation?

Do you have a history of photo-allergy (skin reactions in the sunlight)?

Do you have, or have you had any of the following? ̵ Regional enteritis (crohn's disease) ̵ Ulcerative colitis (inflamed colon and rectum) ̵ Inflammatory bowel disease or antibiotic-associated colitis (including pseudomembranous colitis)

Have you or any of your close family had skin cancer?

Do you currently have sunburn, broken skin or abraded skin?

Do you have any allergic diseases such as asthma, eczema or rhinitis?

Do you have any liver or kidney problems?

Are you currently using any cosmetics, medicated cleansers or scrubbing solutions?

Do you suffer from severe psychological distress because of your acne?

Have you undergone or recently undergone procedures such as depilation, chemical hair treatments, chemical peels, dermabrasion, laser resurfacing of the skin or phototherapy?

Are you sensitive to sunlight or do you have considerable sun exposure?

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. other conditions you have been treated for)

Complete Patient Details

Patients Name

First

Last

Date of Birth (DD/MM/YYYY)

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient GP Consent

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Patient Consent (Other)

I am happy to access treatment from Tabi Health Clinic and not from my GP
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Click to view pharmadoctor terms & conditions.

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Choose type of consultation required

Walk In (done in the clinic, based in Hitchin SG4 9TH)
Online (via video consultation)

Assessment for proton pump inhibitors

Assessment for Esomeprazole

Complete Patient Details

Start Assessment

Complete Patient Details