Patient Information
Are you 18 years old and above?

For females, are you pregnant or breastfeeding?

Patient Symptoms

Do you have any of the following?

• Hypertension (high blood pressure) that is not adequately controlled by present medications
• Edema (swelling due to fluid trapped in your body)
• Primary hyperaldosteronism (adrenal glands produce too much aldosterone)
• Heart failure

For women, do you have menstrual abnormalities?
For men, do you have abnormal breast enlargement?

Medical History

Do you have any of the following?

• Addison’s disease (Problem with your adrenal gland)
• Hyperkalemia (High potassium levels in the blood)
• Kidney disease

Do you have allergies to spironolactone, drugs and food that contain sulfa (trimethoprim-sulfamethoxazoles, mushroom, food
preservatives, ketchup, mayonnaise, etc.)?

Are you taking any of the following medications?

• Other diuretics (amiloride, eplerenone, triamterene)
• Potassium supplements
• Medicines that increase potassium levels (enoxaparin, trimethoprim)
• Other antihypertensives (captopril, enalapril, lisinopril)
• Medicines for heart rhythm diseases (digoxin)

Consent

Do you agree to the following?

• You will read the patient information leaflet supplied with your medication
• You will contact us and inform your doctor 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.