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Medical Assessment

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About You
Are you aged between 18 and 65?
We are unable to supply you with treatment if you are outside of this age range. Please consult your GP.
Please complete this question.
Have you been diagnosed by your GP, nurse or pharmacist with cold sores (herpes labialis)?
We are unable to supply you with treatment if you have not been diagnosed. Please consult your GP.
If you are looking to treat Genital Herpes (HSV-2), click here
Please complete this question.
Your Symptoms
Do you have any of the following symptoms:
  • Mouth ulcers /lumps lasting more than 3 weeks
  • Painful red and white patches on the inside of the mouth
  • Fluid filled blisters/crusts on the lips
If you have any of the above symptoms, you may not be suffering from cold sores and may have another condition. We would not be able to supply you with treatment and would strongly recommend you visit your GP for further advice.
Please complete this question.
Your Health
Are you pregnant, breast feeding or possibly pregnant?
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Do you have an allergy (hypersensitivity) to medicines containing Aciclovir or Valciclovir or Famacilovir or Penciclovir?
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Have you been diagnosed with any of the following conditions?
  • Liver problems
  • Kidney problems
  • Any condition affecting the immune system i.e. cancer, HIV etc
  • Nervous system abnormalities
  • Electrolyte abnormalities
  • Any serious medical condition which may require immediate hospitalisation
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Your Medication
Are you currently taking any medication (including over the counter, prescription or recreational drugs)?
Are you taking any of the following medications?
  • cimetidine (used to treat peptic ulcers)
  • probenecid (used to treat gout)
  • raloxifen
  • medicines that suppress your immune system (e.g. mycophenolate mofetil; ciclosporin; tacrolimus; methotrexate)
  • theophylline and aminophylline (used in asthma and other breathing problems)
  • zidovudine (used in HIV infection)
  • any medicine which affects the kidneys, including aminoglycosides, organoplatinum compounds, iodinated contrast media, pentamidine, foscarnet
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Agreement
Do you understand that if your symptoms are getting worse and the sores have not healed after 10 days you must see your doctor?
If your symptoms are worsening or your sores have not healed after 10 days, this may be a sign of another underlying condition and you must see your GP.
Please complete this question.
Do you understand that outbreak treatment should be initiated at the earliest symptom of a cold sore eg tingling, itching or burning sensation?
Treatment may not be effective if not initiated at the first sign of an outbreak.
Please complete this question.
Do you agree to the following?
  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication 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.
You must agree to this before continuing. If you need assistance contact customer support.
Please complete this question.
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Ana Carolina Osorio De Faria Goncalves
To find a treatment suitable for you, we just need you to answer a few questions.
Ana Carolina Goncalves
Superintendent Pharmacist
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Need help?

If you need help with this medical assessment, contact our helpline:

0207 112 9014

or email us:

help@pharmica.co.uk
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