Medical Assessment for Stop Smoking

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

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About You

Are you aged between 18 and 75?

Yes

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

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Your Health

Are you breastfeeding or pregnant or possibly pregnant?

Yes

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

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Do you have an allergy (hypersensitivity) to Varenicline?

Yes

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

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Do you currently have or had a history of experiencing depression or depressed mood, anxiety, changes in behaviour, suicidal thoughts or any other psychiatric conditions?

Yes

We are unable to supply you with treatment. We recommend consulting NHS services for advice on depression.

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Do you suffer from any of the following?

kidney (renal) disease
history of seizures/epilepsy
diabetes
heart disease/stroke
any serious medical condition which may require immediate hospitalisation

Yes

We are unable to supply you with treatment. Please consult 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?

anti-depression medication
cimetidine for gastric problems
theophylline, warfarin or insulin

Yes

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

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Agreement

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, please contact our customer support.

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Are you aware Varenicline increases your chances of quitting smoking, but you will also need willpower to succeed (help from family and friends will also help)?

Yes

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

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Do you understand that when starting Varenicline treatment, you should start with a 2-week starter pack?

Yes

For more information on how to take treatment, please contact our customer support.

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Do you understand that if you develop agitation, depressed mood, changes in behaviour or suicidal thoughts while taking Varenicline, you should stop taking the treatment and contact your doctor immediately?

Yes

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

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Do you understand that you must stop taking Varenicline and contact your GP or other urgent healthcare provider if you experience any of the following conditions?

new or worse heart or blood vessel (cardiovascular) problems
seizures
agitatation, depressed mood, changes in behaviour, suicidal thoughts
swelling of face, mouth or neck
skin rash or skin peeling

Yes

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

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Do you understand that discontinuation of Varenicline is associated with an increase in irritability, urge to smoke, depression and/or insomnia in up to 3% of patients?

Yes

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

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Do you understand that you should start taking Varenicline 1-2 weeks before you stop smoking?

Yes

For more information on how to take Varenicline, please contact our customer support.

Please complete this question.

Complete