Medical Assessment for Anti-fungal

Patient Information

Are you (or is your child) older than 13 years old?

For females, are you currently pregnant or breastfeeding?

Patient Symptoms

Have you been told by your doctor that you have a fungal infection affecting your skin, hair, nails, mouth, or genitals?

OR

Are you experiencing any of the following symptoms?

• Cottony/creamy white bumps on the tongue/lining of the mouth
• Red, itchy ring-shaped rash
• Small, itchy discolored (lighter or darker) patches on the trunk or shoulders
• Red with fine, silvery scales in between your toes

Medical History
Do you have an allergy to medicines with azoles (e.g. fluconazole, ketoconazole, itraconazole)?

Do you have any of the following?

• Heart disease
• Kidney disease
• Liver disease
• HIV/AIDS
• Cancer

Are you taking any of the following medications?

• Cisapride (for stomach problems)
• Quinidine (for malaria or heart problems)
• Terfenadine (for allergies)
• Pimozide (for mental/movement disorders)
• Erythromycin (for bacterial infections)

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor if you experience any side effects of treatment, if you start new medication, or if your medical conditions change during treatment
• The treatment is solely for your own use
• You have answered all the above questions accurately and truthfully. 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 whilst decisions relating to your treatment are made jointly between you and the prescriber, the final decision to issue a prescription will always be with the prescriber