About the 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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Please state your gender
This refers to your biological gender
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.
Have you had a serious reaction to a varenicline before?
If yes, please describe the product and the reaction
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Women only: Are you breast feeding?
Do you have any allergies?
If yes, please provide details
Do you understand that you must seek prompt medical advice if you develop agitation, depressed mood, or suicidal thoughts whilst taking varenicline?
Do you feel sufficiently motivated to quit smoking (willing to set a quit date between days 8 and 14 of starting treatment)?
Have you received advice from a smoking cessation counsellor before?
If yes, please provide details
Have you tried to quit using nicotine replacement therapy (NRT) before?
Are you on any medicines? Such as antiepileptics, antidepressants, antipsychotics, B-blockers, type 1C antiarrhythmics, cimetidine, theophylline or warfarin?
Do you have a medical history of any of the following: renal / kidney problems, psychiatric illnesses (with symptoms of irritability or depression), myocardial infarction (MI) or risk factors for MI?
Do you understand that varenicline may affect your ability to perform tasks that require judgement or motor and cognitive skills?
Do you agree to receive weekly face-to-face motivational support for the first four weeks at least?
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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