Back Pain Assessment – Walk IN

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Step 1 of 2
Name
Are you currently suffering from, or do you frequently suffer from haemorrhoids?
Have you ever had an allergic or anaphylactic reaction to naproxen, aspirin, ibuprofen or any other medication?
Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Are you breast feeding?
Do you have any kidney problems?
Do you frequently experience rectal bleeding?
Have you been told by your doctor you have a predisposition to rectal bleeding?
Do you have any kidney problems?
Do you have any liver problems?
Are you suffering from severe pain?
Are you already receiving treatment for lower back pain?
Have you been told by your doctor that you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
Do you have (or have you previously had) any problems with your stomach or gut (intestine), such as an ulcer or bleeding?
Do you have difficulties conceiving or are you undergoing investigation of fertility?
Do you have high blood pressure, diabetes, high cholesterol or are you a smoker?
Do you have any heart problems?
Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?
Do you have an autoimmune condition such as systemic lupus erythematosus?
Do you have a history of gastrointestinal diseases such as ulcerative colitis or Crohn's disease?
Do you have osteoporosis?
Do you have asthma, allergies (like hay fever), polyps or rhinitis?
Do you have any allergies?
Please select any of the symptoms/signs below that apply to you
Ask your healthcare professional for advice if you are unsure whether the sign/symptom applies to you

Start Assessment

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Patient Name
Parent or guardian name if applicable
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?