About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Are you experiencing nausea?
Do you realize that if you are unable to consume fluids normally, it is critical to avoid dehydration by drinking little sips of water frequently?
Do you conscent to seeking immediate medical assistance should you suffer the following?
Tummy pain that comes on suddenly.
How frequently do you experience nausea?
Please select your option
Are you experiencing the following?
Have you been vomiting for more than two days?
Do you experience different symptoms other than the ones listed above?
Kindly identify some of the symptoms you experience
You can select more than one option
Has a certified medical practitioner examined about your nausea?
If so, please tell us what they said caused your nausea.
Have you any idea on what could be causing your Nausea?
Notably, if you are unsure about the reason for your nausea, we urge that you visit your doctor for a thorough examination.
For which duration have you been experiencing nausea?
Do you have a history of using Prochlorperazine tablets before?
If yes, how successful was it?
Are you experiencing the following conditions?
Epilepsy.
Can you relate to any of the following?
You have an underlying medical condition
Did you know that?
If your condition does not improve after four weeks, you should consult a doctor.
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.
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
What is your biological gender?
Please select your option
Date of Birth
Use the calendar to select your date of birth.
Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924
Please add your height (in cms).
Your height is important for the prescribers decision.
Please add your current weight (in kgs).
Please make sure to add your current weight. This may affect the prescriber's decision.
Are you currently suffering from nausea (feeling sick) and vomiting (being sick)?
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Do you have a medical history of any of the following?
Renal / kidney problems, Liver problems, Seizure disorders (e.g. epilepsy), Parkinson's disease, Adrenal gland tumour, Methaemoglobinaemia (abnormal blood pigment levels), NADH cytochrome-b5 deficiency, Porphyria, Neurological problems
Do you have any heart problems or QT interval prolongation?
If yes, please provide details
Do you have bleeding, obstruction or a tear in your stomach or gut?
Do you have high blood pressure?
Women only: Have you been through menopause?
If you are male, please select No
Do you have asthma, eczema or rhinitis?
Do you suffer from migraine attacks every day?
Have you had a serious reaction or intolerable side effects to metoclopramide or any other medications before?
If yes, please describe the product and the reaction
Women only: Are you breast feeding?
Do you have any allergies?
If yes, please provide details
Have you been told by your doctor you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
If yes, please provide details
Do you have any problems with the levels of salts in your blood (electrolyte imbalance)?
Do you have a current or previous history of depression, suicidal thoughts, generalised anxiety disorder or any other psychiatric disorder?
Has anyone in your close family died suddenly of heart problems?
Has your doctor told you that you suffer from migraines?
Please provide details in this box here...
Are you a heavy smoker, or do you use nicotine substitution therapies?
Have you ever had tardive dyskinesia (involuntary muscle spasms) when taking a medicine?
If yes, please provide details
Do you currently take any medication whatsoever?
Please list all your current prescription medication including any medication you buy over the counter.
Please provide details of any recent or past medical history of note
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