Medical Assessment for Anti-inflammatory

Patient Information

Are you 12-65 years old?

For females, are you currently pregnant or breastfeeding?

Patient Symptoms
Have you been told by your doctor that you have a condition that needs glucocorticoid/steroid medications OR are you experiencing any of the following?

• Severe allergic reaction to food/medications/chemical
• Asthma attack
• Inflammation in any part of your body

Medical History

Do you have an ongoing systemic infection or amoebiasis?

Are you scheduled to have any of the following vaccines in the next 3 months?

• Measles, mumps, rubella
• Rotavirus
• Chickenpox
• Yellow fever
• Influenza (intranasal)

Have you had a history of any of the following conditions?

• Cataract, glaucoma of the eyes
• High blood pressure/high cholesterol
• Heart failure/heart attack
• Emphysema of the lungs
• Type 1 or type 2 diabetes mellitus
• Peptic ulcer disease
• Osteoporosis

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
• You will consult your doctor if you develop an infection while taking this drug
• You will regularly follow up with your doctor if you're using the drug at high doses and for a long time
• 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