Disclaimer - Haemorrhoids Consultation Form

This questionnaire forms the basis of your consultation today. We require you to be truthful and transparent with your answers including any current medication you are on, your medical history and any other information our prescribers should be made aware of. This allows our prescribers to provide you with the best advice and choice of medication suited to your need. Please read all the medical information before choosing your preferred treatment.

Do you need help completing this questionnaire? Email us or Call us during our working hours (9am - 5pm / Monday - Friday)

Medical Questions

What is your gender?

What is your Date of Birth?

Day

Month

Year

Have you been diagnosed with any medical conditions? Yes | No

If Yes Give Details

Have you ever been diagnosed with a mental health illness? Yes | No

If Yes Give Details

Do you suffer from any allergies? Yes | No

If Yes Give Details

Do you take any medication? This can be prescribed medication or any other over the counter or herbal medicines? Yes | No

If Yes Give Details

Are you currently suffering with haemorrhoids/piles? Yes | No

If Yes Give Details

Please give more details as to why you require this treatment:

Have you previously been diagnosed with haemorrhoids/piles by a doctor? Yes | No

If Yes Give Details

When did you last review your condition with your GP?

How do you know you are suffering from haemorrhoids?

Are your symptoms the same as when you were initially diagnosed by a doctor?

How are your symptoms different this time?

Which of the following symptoms are you currently suffering from?

Itcy bottom

A lump hanging down outside of the anus (which may need to be pushed back in after passing a stool)

A mucus discharge after passing a stool

Small amounts of bright red blood present when wiping the bottom

Soreness

Redness and swelling around your anus.

Do you understand that people aged over 55 should undergo NHS bowel screening?

Do you understand that constipation is a common cause of haemorrhoids/piles?

Do you suffer from any of the following symptoms: First time symptoms over 40 years of age Unexpected weight loss Unexplained rectal bleeding (especially if the blood is darker in colour) Blood in the stools or vomit (may appear dark or sticky) Yes | No

If Yes Give Details

Do you agree to see your doctor if: Your symptoms get worse. There is no improvement in symptoms after seven days of treatment. You experience continuous rectal bleeding, dark or sticky stools, stomach pain or unexpected weight loss.

Have you used Uniroid-HC or Proctosedyl Ointment to treat haemorrhoids/piles before?

Was it effective?

Do you understand that: You should not use Uniroid-HC or Proctosedyl Ointment for more than 7 days. Long-term continuous use of Uniroid-HC or Proctosedyl Ointment can cause increased side effects and thinning of the skin. You should not cover the area of

Do any of the following apply: You are allergic or hypersensitive to Uniroid-HC (hydrocortisone, pramocaine, zinc oxide, balsam peru, benzyl benzoate, bismuth oxide). You have used Uniroid-HC before and suffered serious side effects. You are using Uniroi

Please provide any further information that you think will help our prescriber when reviewing this request for medication. (optional)

Please confirm the below; I confirm I am over 18 years old. The medicine being requested is for my use only. I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages. I take responsibility to inform

Would you like us to notify your GP of the medication you choose to order today?

To continue, please provide your GP's surgery address below.

Product

Proctosedyl Ointment£24.99