Patient Information

Are you 17 years old or older?

For females, are you pregnant or breastfeeding?

Patient Symptoms

Have you been experiencing any of the following symptoms for at least one month?

• Easily dozing off while doing other tasks
• Feeling tired throughout the day despite getting enough sleep

OR

Have you experienced at least 5 of the following?

• Repeating questions/statements in the same day
• Forgetting appointments/medications
• Misplacing items more than once a month
• Difficulty knowing the date, day, month, year, time
• Difficulty completing home tasks
• Difficulty handling money (tips, calculating change)
• Trouble paying bills
• Trouble using appliances
• Feeling confused when in unfamiliar places
• Getting lost in familiar places
• Confusing names of family members/friends
• Trouble finding words other than names

Medical History

Have you had any of the following?

• Uncontrolled hypertension (high blood pressure)
• Heart disease
• Severe kidney/liver disease
• Epilepsy/seizure fits
• Huntington’s chorea (involuntary jerking or writhing movements)
• Depression, major anxiety
• Stroke due to a bleed in the brain

Have you had a serious allergic reaction to any drug/food?

Are you taking any of the following?

• Blood thinners (aspirin, clopidogrel, warfarin)
• Recreational drugs (marijuana, cocaine, heroin)

Consent

Do you agree to the following?

• You will take the medicine as directed by your doctor or as indicated in the information leaflet supplied with the medication
• You will contact us and inform your doctor 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