• Important
  • Ventolin
  • Other medicines
  • Current health
  • Consent
Our doctors would now like to check your suitability for this product

How did you hear about us?

Before you start, you need to know

I confirm the above statements are true --This service is not suitable for urgent asthma, COPD or breathing problems
--If you are struggling with your breathing, having an asthma attack or have any chest pains or discomfort call 999 and go to A+E immediately
--A patient with well controlled asthma experiences; symptoms less than 3 times a week during the day, no symptoms during activity or exercise, no symptoms at night and a reliever inhaler would last between 4-6 months before running out
--We will notify your GP about the outcome of your consultation to ensure safe ongoing care.
--We may give advice on either stepping up or stepping down your asthma treatments based on asthma guidelines

This questionnaire forms the basis of your online consultation. Please be honest and if you are unsure about any of your answers, please verify the information with your GP before using the service:

--I am 18 years old or above.
--I am using this service on my own behalf and of my own free will. Any treatment or advice is for my sole use only.


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Your Ventolin inhaler

What is your sex?

What is your date of birth?

Has a clinician previously prescribed Ventolin (salbutamol) to you?

Why do you use a Ventolin inhaler?

Roughly how many Salbutamol inhalers have you used in the last 12 months?

Have you ever needed an emergency nebuliser from your GP or in hospital?

Please enter your height(cm).

Please enter your weight(kg).


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Your inhalers

Are you taking any other inhalers or tablets for your condition?


Current and recent use of medicines

Are you taking any prescription-only medicines, over-the-counter medicines, alternative medicines or recreational drugs?

In the last two months have you taken any medicine, including both prescription and non-prescription medicines, other than any medicine you have mentioned above?


Allergies

Are you allergic to any of the following? Please select all that apply.

Do you have any other known allergies?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Your medical history

Do you or have you ever suffered from any heart conditions including angina and problems with heart rhythm?

Have you ever had Tuberculosis (TB) in your lungs?

Do you suffer from any of the following?

Other than those already mentioned, do you have any other significant medical conditions, illnesses or past surgical procedures?


Pregnancy and breastfeeding

How do I know if I\'m pregnant?

Are you breastfeeding?


Smoking

Do you smoke?


We want to offer you high quality, safe care. To do this we need you to be honest with your answers. Serious clinical errors could occur if you don't give us accurate information. Thank you for using our service.

Informed consent

I confirm the above statements are true --I have responded honestly and provided complete and accurate information that reflects my up to date medical history and information, so that the doctor can safely assess and advise me.
--I fully understand all the questions and information provided. If I am unsure about any aspect of the service I will contact Your Chemist Online Doctor before proceeding
--I understand the side effects, effectiveness and alternatives to the treatment I am requesting.
--I understand this consultation will form part of my Online Doctor medical record and will be kept in line with the relevant retention period.
--I have read, understand and agree to the latest terms and conditions and privacy policy


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