Asacol/Mesalazine

* Have you ever been prescribed this item?

* If yes, how long have you been using this?

* When were you last prescribed this item?

* What was the prescribers directions/dosage? (For example, take 200mg daily)

* Are you currently under the care of a clinician who monitors your treatment with this medicine?

* Why are you ordering this item from Pharmacy Planet today?

* When did you last have a review of this medication with your normal doctor?

* Were any issues raised at your last review?

* If yes, please describe

* When were you diagnosed as suffering from Inflammatory Bowel Disease?

* What symptoms do you experience?

* If Other, please list additional symptoms

* Do you suffer from any of the following condition?

• Unexplained weight loss
• Difficulty swallowing
• Liver or kidney disease
• Severe or persistent diarrhoea
• Black stools (blood stained fasces)
• Vomiting food or blood
• Sugar intolerance
• History of gastric ulcers or surgery
• Persistent loss of appetite
• Cancer
• Porphyria

* If yes, please note your symptoms:

* Other than pharmaceuticals, how else do you manage your symptoms?

* Does your doctor schedule regular blood tests to monitor your body's response to this medicine?

* Do you suffer from any of the following conditions:

• Sensitivity or allergy to salicylates (including aspirin) or sulfonamides
• Kidney Problems
• Liver Problems
• Lung Problems (including asthma)
• Porphyria

* If yes, please describe

* Have you recently experienced any of the following?

• Unexplained Weight loss
• Rectal bleeding or blood in your stool
• A hard lump or swelling in your tummy
• A persistent change in your bowel habits
• Abdominal pain, discomfort or bloating brought on by eating

* If yes, please describe

* Are you pregnant or breast feeding? Or do you intend to become pregnant?

* Anything else you would like us to know? (Please tell us anything you think may be important for the prescriber to be aware)

* If yes, please let us know here

* Please confirm that you will consult your usual doctor immediately if you experience any of the following symptoms:

• Fever, sore throat, mouth or lip ulcers, spots underneath your skin anywhere on your body, including the genital and anal regions, become very pale, swollen ankles or have unusual bleeding (e.g. unexpected nosebleeds or bleeding gums)
• Skin rash with flaking, boils or sore lips or mouth
• Bruising more easily or suspect blood abnormalities
• Problems with kidney function

* Please confirm acceptance of the following:

• You are ordering the medication for yourself.
• You have answered the questions truthfully. 
• Before taking the medicine you will read the enclosed patient information leaflet and follow the guidance issued by the manufacturer. 
• You will contact your GP/Doctor if you suffer from any unwanted side effects or if your condition is deteriorating.
• You give permission for Pharmacy Planet to access your summary care records, if clinically necessary for patient safety.
• Decisions regarding treatment are for joint consideration between yourself and the prescriber. However, the final decision will be the prescribers.