Diclofenac Potassium for Gout

* Have you ever been prescribed this item?

* When were you first prescribed this medicine?

* When were you last prescribed this item?

* What was the prescribers directions/dosage?

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

* Were any issues raised at your last review?

* Please provide further details below

* 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?

* Other than anti-inflammatories, do you use any other medicines to manage your gout symptoms?

* Please provide further details below

* Do you have a history of problems affecting the gastro-intestinal system, including:

• Peptic or Duodenal Ulcers
• Gastro-intestinal bleeding or perforation
• Gastro-intestinal disease (such as Ulcerative Colitis, Crohns Disease, etc)
• Haemorrhoids or rectal bleeding
• Congestive or atrophic gastritis ?

* Please provide further details below

* Do you currently or have you ever suffered from any of the following conditions:

• Liver or Kidney problems
• Porphyria
• High blood pressure (hypertension)
• Heart problems (including a history of angina, blood clots, high cholesterol, heart attack, stroke, heart failure, heart disease)
• Circulation problems (peripheral arterial disease)
• Fluid retention
• Blood or bleeding disorders
• Asthma
• Diabetes
• Systemic Lupus Erythematosus ?

* Please specify which condition and provide further details below

* Have you ever experienced any of the following symptoms after taking this or a similar medicine (such as Aspirin, Ibuprofen, Naproxen, Diclofenac, Aceclofenac, Indomethacin, Mefenamic Acid, Celecoxib, Etoricoxib, NSAIDs [Non Steroidal Anti-Inflammatory Drugs]):

• Anaphylaxis
• Asthma or Shortness of Breath
• Angioedema (severe allergic swelling of the lips, mouth, tongue, throat, face, abdomen, and/or limbs)
• Urticaria (hives)
• Any serious skin reactions (including exfoliative dermatitis, Stevens-Johnson syndrome, toxic epidermal necrolysis)
• Acute Rhinitis (hayfever or cold-like symptoms)
• Nasal Polyps ?

* Please specify which condition and provide further details below

* Have you recently had surgery or do you intend to have surgery in the near future?

* Please provide further details below

* Do you consume alcohol regularly?

* How many units of alcohol do you consume in an average week?

* Please confirm your understanding and 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.
• If you are purchasing this item for use in the eye, and you wear contact lenses, you will follow manufacturers guidance regarding concurrent use. 
• 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.
• All images of products are illustrative only
• Decisions regarding treatment are for joint consideration between yourself and the prescriber. However, the final decision will be the prescribers.