Arthritis

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

1

Please state your gender

This refers to your biological gender

Male

Female

2

Date of Birth

Use the calendar to select your date of birth.

3

Please add your height (in cms).

Your height is important for the prescribers decision.

4

Please add your current weight (in kgs).

Please make sure to add your current weight. This may affect the prescriber's decision.

5

Do you drink alcohol?

If so, please tell us how many units per day. You can use the following as a guide:

- Pint of beer = 3 units
- A can of beer = 2 units
- A large glass of red wine = 3 units

Yes

No

6

Do you smoke?

If you do, please write how many cigarettes you smoke per day. Or, if you vape, please tell us about this.

Yes

No

7

Do you know if your blood pressure is Low, Normal or High? Please write LOW, NORMAL or HIGH

Use the following as a guide:

Low = Under 90/60
Normal = Between 90/60 and 140/90
High = Over 140/90

8

Have you previously had a transient ischaemic attack (mini stroke) or stroke?

Yes

No

9

Can you walk 3 miles or climb a set of stairs without pain in your chest?

If you cannot, please provide more information

Yes

No

10

Do you suffer from any allergies?

If you do, kindly explain them below

Yes

No

11

Do you currently take any medication whatsoever?

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

Yes

No

12

Have you ever had any surgery (operations)?

If so, please provide more details

Yes

No

13

Have you recently finished any course of medication?

Yes

No

14

Is there a history of medical disorder's within your family?

If so, please provide more information

Yes

No

15

Are you currently receiving any treatment or under any medication?

Please provide more information of the medication being used if any.

Yes

No

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

16

Have you been diagnosed with arthritis or gout by your GP or any consultant?

Yes

No

17

Can you confirm that you have an arthritic condition such as osteoarthritis or rheumatoid arthritis?

If so, please provide more information

Yes

No

18

Have you experienced increased joint stiffness during morning or afternoon activity?

Yes

No

19

Are any of your joints swollen or red?

Yes

No

20

Have you previously tried any medication to treat this condition?

If so, which medicines have you tried?

Yes

No

21

Please specify which drug you want to try for your condition and why

22

Do you have any problems with your stomach or gut (intestine), such as an ulcer or bleeding?

Yes

No

23

Do you suffer from heart failure?

If so, please provide more info

Yes

No

24

Are you aware of any disease in your liver or kidney?

Yes

No

25

Do you have a history of gastrointestinal diseases such as ulcerative colitis or Crohn's disease?

Yes

No

26

Do you have any autoimmune condition such as systemic lupus erythematosus?

Yes

No

27

Do you have severe sudden pain in your joints?

Yes

No

28

Have you ever had an allergic response to arthritic medication?

Yes

No

29

Are you taking any of the following medicines?

- Anticoagulants
- Lithium
- Methotrexate
- Cyclosporin

Yes

No

30

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

Yes

No

31

Women only: are you currently breast-feeding?

If you are male, answer No

Yes

No

32

Have you ever taken the medication you are requesting before?

Yes

No

33

Can you think of any other health / medical details not mentioned above?

Yes

No

34

Is there anything else which you feel we should know about prior to you taking this medication?

Yes

No

Complete assessment form

To help us understand that this treatment is the right option for you, please answer the following questions.

35

Do you agree to the following?

- You declare that I have answered the above truthfully
- You will read the patient information leaflet before taking your medication (if prescribed)
- 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
- 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 understand that this questionnaire is part of a request to the doctor and the final decision will rest with the doctor

Yes

No

36

Can we share this information with your General practitioner?

Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advise you share this treatment with your doctor for him/her to update your medical records.

Yes

No

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Unfortunately we cannot offer you any treatments for this condition.
Please feel free to contact us for more information.

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Complete assessment form

Complete assessment form

Complete assessment form