Are you aged between 18 and 65?

Have you been diagnosed by your GP, nurse or pharmacist with cold sores (herpes labialis)?

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

cimetidine (used to treat peptic ulcers) probenecid (used to treat gout) raloxifen medicines that suppress your immune system (e.g. mycophenolate mofetil; ciclosporin; tacrolimus; methotrexate) theophylline and aminophylline (used in asthma and other breathing problems) zidovudine (used in HIV infection) any medicine which affects the kidneys, including aminoglycosides, organoplatinum compounds, iodinated contrast media, pentamidine, foscarnet

Do you understand that outbreak treatment should be initiated at the earliest symptom of a cold sore eg tingling, itching or burning sensation?

Do you understand that if your symptoms are getting worse and the sores have not healed after 10 days you must see your doctor?

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.

Do you have an allergy (hypersensitivity) to medicines containing Aciclovir or Valciclovir or Famacilovir or Penciclovir?

Are you pregnant, breast feeding or possibly pregnant?

Have you been diagnosed with any of the following conditions?

Liver problems Kidney problems Any condition affecting the immune system i.e. cancer, HIV etc Nervous system abnormalities Electrolyte abnormalities Any serious medical condition which may require immediate hospitalisation

Do you have any of the following symptoms:

Mouth ulcers /lumps lasting more than 3 weeks Painful red and white patches on the inside of the mouth Fluid filled blisters/crusts on the lips