Medical Assessment for Antibiotic (Cough, sore throat, sexually transmitted infections)

Patient Information

Are you over 65 years old?

For females, are you currently pregnant or breastfeeding?

Patient Symptoms

Have you been told by your doctor that you have a bacterial infection in the lungs (pneumonia), sinuses, or skin, chlamydia, or gonorrhea

OR are you experiencing any of the following symptoms?

• Fever
• Cough with phlegm
• Shortness of breath
• Runny nose with thick, yellow/greenish discharge
• Penile/vaginal discharge

Medical History

Do you have any of the following conditions?

• Hearing problems
• Myasthenia gravis
• Heart arrhythmia (irregular heartbeat)
• Liver disease
• Kidney disease
• Hypokalemia (low potassium levels in the blood)
• Hypomagnasemia (low magnesium levels in the blood)

Do you have allergies to these antibiotics?

• Azithromycin
• Erythromycin
• Clarithromycin

Are you taking any of the following drugs?

• Quinidine, procainamide, amiodarone (For heart rhythm)
• Warfarin (For bleeding)

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