About your condition and treatment
To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.
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Do you have any recent or past medical history of note?
If yes, please provide details
Have you had a doctor/nurse asthma review within the past year?
Within the past year, have you been prescribed generic (unbranded) salbutamol?
If not, please list the name of the medicine
Do you know how to use your inhaler properly?
I agree to read the patient information leaflet contained within the box of the salbutamol inhaler.
Do you have a medical history of the following: heart conditions (cardiovascular disease) such as arrythmias, susceptibility to prolonged QT-interval or hypertension; hypokalaemia, hyperthyroidism, diabetes?
If yes, please provide details
Is your asthma controlled well with your current medical regime?
Have you had a serious reaction to a medicinal inhaler before?
If yes, please describe the product/reaction
Do you use your inhaler more than two puffs, four times a day?
I agree to seek further medical help if my asthma does not improve within an hour after my first dose.
Do you take any current or repeat medicines? (eg. oral asthma tablets) If yes, please list them below...
Please write below any further information which may be relevant e.g. medicines, conditions…
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The Agreement
Please answer the following questions to help us confirm that you'll follow the guidelines for this medicine.
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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, 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.
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