Medical Assessment for Antibiotic (Diarrhea)

Patient Information  

Are you (or is your child) older than 12 years old?

For females, are you currently pregnant or breastfeeding?

Patient Symptoms

Are you currently experiencing diarrhea or loose stools?

Is your diarrhea accompanied by fever and/or blood in the stool?

Have you tested positive for shigellosis or salmonellosis?

Medical History

Do you have allergies to rifaximin, rifampicin, rifabutin, or rifapentine?

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