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Q No.	Question	Answer
1	Are you pregnant or breastfeeding or trying to become pregnant?Bottom of Form You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
2	Do you have any problems with your liver or kidneys? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
3	Do you know what is causing your pain? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
4	Have you used the treatment you are requesting before and did it help with the pain? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
5	Have you seen your GP about your pain? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
6	Are you currently seeing, or have you recently seen, a hospital specialist? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
7	Do any of the following symptoms accompany your pain? Redness of the painful area Swelling of the painful area Bruising Weakness Broken skin Area is painful to touch Nausea You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
8	Are you currently taking any medication to relieve your pain? You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
9	Do you agree to see your GP if: Your pain doesn’t improve with treatment Your pain worsens with or without treatment You’re in severe pain Your pain spreads to new areas Your pain impacts your quality of life You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
10	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 are over the age of 18 and you have entered your own information for our identity verification checks You have answered all the above questions accurately and truthfully You understand our doctors take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo
11	What is the name of your GP surgery and do you consent to us contacting them about your treatment? You must answer this question. You must answer this question. Please write your explanation in the box below
12	Do you consent to us accessing your GP records? This is advised so we can clinically assess suitability. You must answer this question. You must answer this question. Please write your explanation in the box below	YesNo

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