Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Do you require melatonin for the treatment of jet lag?

Yes

We can only provide melatonin for the treatment of jetlag.

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Your Health

Are you pregnant or breastfeeding?

Yes

We are unable to prescribe you melatonin if you are pregnant or breastfeeding.

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Do you have an allergy to lactose or melatonin?

Yes

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)

Yes

We are unable to supply you with this treatment. Please see your GP.

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Your Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes

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

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

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

Yes

We are unable to supply you with this treatment. Please see your GP.

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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?

Yes

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.

Yes

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?

Yes

We are unable to supply you with this treatment.

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Do you understand that you should not take melatonin with alcohol?

Yes

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.

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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, you start new medication and/or 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

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

Please complete this question.

Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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