Asthma - Medical Assistment

If you have ordered this medication before, you can log in to fill up the questionnaire automatically.

About You

Do you know how and when to use your inhaler?

You must answer the question to continue.
We are unable to supply you with treatment if you do not know how or when to use an inhaler. Please consult your GP or asthma clinic.
Symptoms

Have you called an ambulance or had emergency treatment for breathing problems in the last year?

You must answer the question to continue.
We are unable to supply you with treatment. Please consult your GP.
 

Do you use your inhaler more than four times a day?

You must answer the question to continue.
We are unable to supply you with treatment as you are using the inhaler more than the recommended dosage. Please consult your GP or asthma clinic.
 

Have you been diagnosed with asthma by your doctor or nurse?

You must answer the question to continue.
We are unable to supply you with treatment if you have not been diagnosed with asthma by a doctor or nurse. Please consult your GP.
Health

Has your Asthma been reviewed by a doctor or nurse within the last 12 months?

You must answer the question to continue.
We are unable to treat you if you have not had an asthma review recently. Please consult your GP or asthma clinic.
 

Have you been prescribed Ventolin (salbutamol) in the last 12 months?

You must answer the question to continue.
We are unable to treat you if you have not been prescribed Ventolin (salbutamol) recently. Please consult your GP or asthma clinic.
 

Is your asthma well controlled?

If you are not sure take the asthma control test here.

You must answer the question to continue.
We cannot offer you treatment if your asthma is not in control.
 

Do you have an allergy (hypersensitivity) to Ventolin (salbutamol) or have you had a reaction with an asthma inhaler previously?

You must answer the question to continue.
We are unable to supply you with treatment. Please consult your GP.
 

Are you breast feeding or pregnant or planning to become pregnant in the next 6 months?

You must answer the question to continue.
We are unable to supply you with treatment. Please consult your GP.
 

Have you been diagnosed with any of the following?

  • Overactive thyroid gland
  • History of heart problems such as an irregular or fast heartbeat or angina
  • High blood pressure
  • Any serious medical condition which may require immediate hospitalisation
You must answer the question to continue.
We are unable to supply you with treatment. Please consult your GP.
Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

You must answer the question to continue.
 

Are you taking any of the following medications?

  • medicines for an irregular or fast heartbeat
  • medicines for your asthma (apart from your existing inhaler ) such as oral asthma tablets
  • xanthine derivatives (such as theophylline) or steroids to treat asthma
  • water tablets (diuretics), sometimes used to treat high blood pressure or a heart condition
You must answer the question to continue.
We are unable to supply you with treatment. Please consult your GP.
Agreement

Do you understand that you must seek medical attention if your asthma does not improve within 1 hour of using your inhaler?

You must answer the question to continue.
Call our helpline for more information. We cannot continue if you do not understand this.

Do you agree to the following?

  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You must answer the question to continue.
You must agree to this before continuing. If you need assistance contact customer support.
You must click on the terms and conditions to continue
01273 204 905

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hello@burwashmedsdirect.co.uk

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Mon – Fri 09:00 – 18:00

Saturday 09:00 – 13:00

Sunday Closed