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Medical Assessment

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About You
Do you require melatonin for the treatment of jet lag?
We can only provide melatonin for the treatment of jetlag.
Please complete this question.
Your Health
Are you pregnant or breastfeeding?
We are unable to prescribe you melatonin if you are pregnant or breastfeeding.
Please complete this question.
Do you have an allergy to lactose or melatonin?
Sorry, this product is not suitable for you
Please complete this question.
Do you have any of the following?
  • Kidney problems
  • Liver problems
  • Heart problems
  • Any Autoimmune condition (e.g. Rheumatoid arthritis, Graves’ disease)
  • Galactose intolerance, LAPP lactase deficiency or glucose-galactose malabsorption
  • Alcohol dependency
  • Depression requiring treatment with medication Schizophrenia or Bipolar Disorder Epilepsy (or ever suffered a seizure)
We are unable to supply you with this treatment. Please see 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?
  • Benzodiazepines (e.g. Diazepam, temazepam, lorazepam)
  • Zopiclone or Zolpidem (or any other sleeping tablets)
  • Fluvoxamine
  • Oestrogen containing medication (e.g. HRT or combinec contraceptive pill)
  • Warfarin or any other blood thinning medication
  • carbamazepine
  • rifampicin quinolones or fluoroquinolones (e.g. Ciprofloxacin)
  • pipemidic acid
  • teriflunomide
  • leflunomide
  • axitinib
We are unable to supply you with treatment. Please consult your GP.
Please complete this question.
Melatonin, as a medication that helps you sleep, can enhance the effects of sleepiness or low blood pressure when taken with other medications. Below is a list of medications whose side effects could be enhanced by melatonin. Do you understand that if you are on these medications and have any symptoms of light headedness, muzziness or excessive sleepiness you should immediately stop your melatonin?
  • Alcohol
  • Alpha-blockers (e.g. Doxazocin, Alfuzosin, Tamsulosin, Prazocin)
  • Antidepressants, Tricyclic
  • Antihistamines
  • Antipsychotics
  • Myelosuppressive drugs
  • Baclofen
  • Beta-blockers
  • Calcium-channel Blockers
  • Clonidine
  • Diazoxide
  • Diuretics
  • Guanfacine Hydralazine
  • Lofexidine
  • Methyldopa
  • Minoxidil
  • Mirtazapine
  • Moxonidine
  • Nitrates
  • Opioid Analgesics
  • Phenobarbital
  • Primidone
  • Ritonavir
  • Sodium Nitroprusside
  • Tizanidine
We are unable to supply you with this treatment. Please see your GP.
Please complete this question.
Agreement
Do you understand that melatonin can cause drowsiness and therefore you should not drive or operate heavy machinery for at least 8 hours after taking it?
We are unable to supply you with this treatment.
Please complete this question.
Do you understand that melatonin should be taken daily, at your intended bedtime in your new time zone? It should only be taken between the hours of 8pm and 4am and should not be taken for more than 5 days.
Please read the melatonin product information and change your answer.
Please complete this question.
Do you understand that recent studies have suggested melatonin may increase the risk of falls, accidents, memory disturbance, dependence and withdrawal symptoms and an increased risk of dementia?
We are unable to supply you with this treatment.
Please complete this question.
Do you understand that you should not take melatonin with alcohol?
Both melatonin and alcohol have sedative effects, and combining them can be dangerous. Taking melatonin following a small intake of alcohol (up to 2 units) is unlikely to be harmful, however there is always a risk, and this risk increases the more alcohol you drink. If you accept this risk, change your answer and continue.
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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