Questions

Have you previously tried any over-the-counter pain medication?

Please state your weight (stone/ kg) and height (meters /feet)

Please note date supplied, strength, dose and quantity.

Have you had this medication from your GP before?

Do you have a registered GP in the UK?

If you have previously used this medication before, and using the same 1 – 10 pain rating scale, how much does the medication reduce your average pain levels.

Think about your pain on a scale of 1 – 10 where 1 is being free from pain and 10 is the worst pain imaginable, what level is your usual daily pain?

Have you been diagnosed with hypertension (high blood pressure 140/90mmHg or higher)?If you do not know your blood pressure you can have this measured at your local pharmacy/GP surgery.

Have you undergone any recent surgeries? If yes, list the date(s), type of surgery ; condition treated, and medical status.

Have you experienced any allergies, side-effects or adverse effects or with any medications? If yes, please describe the medicine causing the reaction, the nature of the reaction and when it happened.