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Medical Assessment for Heartburn Relief

Complete this short online consultation so our medical team can show you suitable treatments.

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Tell us about yourself
Are you aged 18 or over? (You must be at least 18 years old to complete this medical consultation and receive treatment.)
About Your Symptoms
If you are over the age of 50, please let us know whether you’ve experienced any new symptoms or recent changes in your usual health pattern, so we can ensure the treatment you receive is safe and suitable.
When acid reflux happens twice weekly or more, do you experience any of the following symptoms?

Heartburn â€“ a burning sensation in the centre of the chest, usually behind the breastbone, often after eating and lasting minutes to hours.

Chest discomfort or pain, especially after meals, when bending forward, or when lying down.

A burning feeling in the throat, or a hot, sour, acidic or salty taste at the back of the mouth (acid regurgitation).

A sensation of food sticking or slowing down in the chest or throat when swallowing (dysphagia).

A persistent cough, particularly at night or after eating.

Hoarseness or a sore throat, especially in the morning, caused by acid irritation.

Frequent burping or belching, especially after eating.

An unpleasant taste in the mouth, or bad breath linked to acid reflux.

A feeling of a lump in the throat (also known as “globus sensation”).

Bloating or discomfort in the upper abdomen, particularly after meals.

Nausea, sometimes occurring after eating or on waking.

 

Do you currently have any of the following symptoms?

Difficulty swallowing or feeling as though food is getting stuck

Unintentional or unexplained weight loss

Swelling or noticeable bloating of the abdomen

Ongoing or repeated vomiting that does not settle

Severe or persistent diarrhoea

Vomiting blood (which may appear red or like coffee grounds)

Blood in the stool, or black, tar-like stools

A diagnosis of iron-deficiency anaemia

Known severe liver disease or significant liver problems

 

Your Health Information
Are you currently pregnant, breastfeeding, or is there a possibility that you may be pregnant?
Have you ever had an allergic reaction to proton pump inhibitor medicines (PPI), for example Omeprazole, Lansoprazole, Pantoprazole, Rabeprazole, or Esomeprazole?
Please let us know if you have any of the following health conditions, as this may affect treatment suitability.

Osteoporosis â€“ a condition where the bones become thinner, weaker, or more fragile, increasing the risk of fractures (broken bones), especially in the spine, hip, or wrist.

Liver problems or liver disease â€“ for example, a history of hepatitis, cirrhosis, fatty liver disease, abnormal liver function tests, or if you have been told by a doctor that your liver does not work normally.

Gastric (stomach) cancer â€“ a current or previous diagnosis of stomach cancer, or if you are undergoing tests or investigations with your GP or specialist to rule out stomach cancer.

Hypomagnesaemia (low magnesium in the blood) â€“ a diagnosed low magnesium level, or if you take regular magnesium supplements because your doctor has told you your magnesium is low, sometimes causing symptoms such as muscle cramps, weakness, tremors, or abnormal heart rhythms.

At any point while taking a proton pump inhibitor, have you developed a ring-shaped or plaque-type rash following exposure to sunlight?
Your Current Medication
Are you taking any medicines right now such as prescription medicine, shop-bought treatments, herbal supplements, or recreational drugs?
Patient Declaration & Agreements
Do you agree to the following? Please read each statement carefully before confirming. This ensures you understand how your treatment will be supplied and used safely.

☑️ I will read the Patient Information Leaflet provided with my medication before use.

☑️ I will contact ifeelshy and inform my GP immediately if I experience any side effects, start a new medication, or if my medical conditions change during treatment.

☑️ I understand that the treatment is for my personal use only and will not be shared with anyone else.

☑️ I confirm that I have answered all questions accurately and truthfully to the best of my knowledge.

☑️ I understand that the prescriber relies on my answers in good faith, and that providing incorrect or incomplete information could affect my health.

☑️ I understand that while treatment decisions are made jointly between myself and the prescriber, the final decision to issue a prescription rests with the prescriber.

Please confirm that this medicine is for short-term use only (up to 28 days), that lifestyle changes such as healthy eating, reducing alcohol, maintaining a healthy weight and stopping smoking can help relieve symptoms, and that you will contact your GP if symptoms do not improve within 14 days