Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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About You

Are you aged between 18 and 65?

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Do you know how and when to use your inhaler?

Yes

We are unable to supply you with treatment if you do not know how or when to use an inhaler. Please consult your GP or asthma clinic.

Please complete this question.

Your Symptoms

Do you use your inhaler more than four times a day?

Yes

We are unable to supply you with treatment as you are using the inhaler more than the recommended dosage. Please consult your GP or asthma clinic.

Please complete this question.

Have you been diagnosed with asthma by your doctor or nurse?

Yes

We are unable to supply you with treatment if you have not been diagnosed with asthma by a doctor or nurse. Please consult your GP.

Please complete this question.

Have you called an ambulance or had emergency treatment for breathing problems in the last year?

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Your Health

Are you breast feeding or pregnant or planning to become pregnant in the next 6 months?

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Do you have an allergy (hypersensitivity) to Ventolin (salbutamol) or have you had a reaction with an asthma inhaler previously?

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Has your Asthma been reviewed by a doctor or nurse within the last 12 months?

Yes

We are unable to treat you if you have not had an asthma review recently. Please consult your GP or asthma clinic.

Please complete this question.

Have you been diagnosed with any of the following?

Overactive thyroid gland
History of heart problems such as an irregular or fast heartbeat or angina
High blood pressure
Any serious medical condition which may require immediate hospitalisation

Yes

We are unable to supply you with treatment. Please consult your GP.

Please complete this question.

Have you been prescribed Ventolin (salbutamol) in the last 12 months?

Yes

We are unable to treat you if you have not been prescribed Ventolin (salbutamol) recently. Please consult your GP or asthma clinic.

Please complete this question.

Is your asthma well controlled?
If you are not sure take the asthma control test here.

Yes

We cannot offer you treatment if your asthma is not in control.

Please complete this question.

Your Medication

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes

Are you taking any of the following medications?

medicines for an irregular or fast heartbeat
medicines for your asthma (apart from your existing inhaler ) such as oral asthma tablets
xanthine derivatives (such as theophylline) or steroids to treat asthma
water tablets (diuretics), sometimes used to treat high blood pressure or a heart condition

Yes

We are unable to supply you with treatment. Please consult your GP or doctor for more information.

Please complete this question.

Agreement

Do you understand that you must seek medical attention if your asthma does not improve within 1 hour of using your inhaler?

Yes

Call our helpline for more information. We cannot continue if you do not understand this.

Please complete this question.

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, you start new medication and/or 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

Yes

You must agree to this before continuing. If you need assistance contact our customer support.

Please complete this question.

Medical Assessment

To help us supply you with the most suitable treatment, please complete this online consultation.

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