1 IMPORTANT!2 Your Condition & Your Health3 Product Choice4 Details & PaymentWe will now ask you some questions to assess your suitability for a prescriptionJust before you start, it is important that you read this:Welcome to our online clinic. This questionnaire forms the basis of today's consultation. We need you to be honest with your answers so we can prescribe medication safely and give you the right advice. If you forget to tell us something or give inaccurate information, this may result in a drug being prescribed that harms rather than helps you. It's important that you tell us about any medication you are already taking when we ask for this.PLEASE READ THIS STATEMENT, AND CHECK THE BOX IF YOU WISH TO PROCEED*I ACKNOWLEDGE THE ABOVE AND COMMIT TO ANSWERING QUESTIONS FULLY AND HONESTLY Confirmations Regarding The Use of DiamoxI understand that taking Diamox (acetazolamide) does NOT replace acclimatisation?**YesNoI understand Diamox is not advised where normal acclimatisation recommendations are followed*YesNoI understand Mountain sickness and serious HAPE and HACE can still occur whilst taking Diamox*YesNoI understand sleep disturbance of altitude is treated with 125mg (half a tablet) Diamox twice daily*YesNoI understand proper acclimatisation is important alongside this medicine*YesNoI confirm I will read the dosage and the patient information leaflet for the medicine to be taken correctly?*YesNoCan you confirm you understand the following Diamox (acetazolamide) doses and information?**YesNo Early mild acute mountain sickness (headache, fatigue, dizziness, loss of appetite) – Diamox 250mg (one tablet) twice daily Rapid forced ascent - Diamox 250mg (one tablet) twice daily Ascent of more than 500 metres (1,500 feet) a day above 3,000 metres (10,000 feet) is dangerous with or without Diamox (acetazolamide). Taking Daimox (acetazolamide) will help with these symptoms. The important thing is not to ascend until the symptoms resolve. Any loss of co-ordination and extreme shortness of breath requires immediate descent and also possible, steroids, oxygen, hyperbaric oxygen and acetazolamideYour HealthDo you suffer from any problems with your kidneys, your urinary system, your digestive system or your liver?**NoYesPlease Give Details*Do you have any other health problems or conditions?*NoYesPlease Give Details*Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs?**NoYesPlease Give Details*Do you have any known allergies to any medicine or substances especially Diamox (acetazolamide) or sulphur containing medication?**NoYesPlease Give Details*Are you pregnant or planning to become pregnant or breastfeeding?**NoYesPlease Give Details*ConsentI confirm I am over 18 years old. The medicine ordered is for my sole use only. I will read the patient information leaflet supplied with the medicine or obtain it from the website. I will pay particular attention to the side effects and dosages. I take responsibility to inform my own GP of the online consultation or any changes in my circumstances. I agree to the terms and conditions.I confirm I agree to the above, and have answered questions accurately*NoYes To help you decided how many Diamox you need, please read the following dosage advice.For Mild Acute Mountain Sickness dose is One Tablet Twice DailyWhen rapid ascent without proper acclimatisation cannot be avoided, take one tablet twice daily, and continue for two to three days after reaching final altitudeFor disturbed breathing patterns during sleep, take half a tablet twice daily, and continue until at an altitude where breathing will return to normalChoice of Medication*Diamox (Acetazolamide) 250mg x 28 - £19.50Diamox (Acetazolamide) 250mg x 56 - £33.50Diamox (Acetazolamide) 250mg x 84 - £56.50Please select the quantity you requirePrescription Charge £ 5.00Total £ 0.00 Name* First Last Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address* Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Phone* This iframe contains the logic required to handle AJAX powered Gravity Forms.