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

NSAID anti-inflammatory painkillers (e.g. ibuprofen) Ketoconazole, itraconazole, posaconazole or voriconazole (used to treat infections caused by a fungus) Digoxin (used to treat heart problems) Diazepam (used to treat anxiety, relax muscles or in epilepsy) Ulipristal (used as emergency contraception or treatment for fibroids) Phenytoin or Fosphenytoin (used in epilepsy) Medicines that are used to thin your blood, such as warfarin or other vitamin K blockers. Rifampicin (used to treat tuberculosis) Atazanavir, Rilpivirine, Tripranavir, Saquinavir, Nelfinavir, Raltegravir (used to treat HIV infection) Ledipasvir (used for Hepatitis C treatment) Ciclosporin or Tacrolimus (in cases of organ transplantation) St John's wort (Hypericum perforatum) (used to treat mild depression) Cilostazol (used to treat intermittent claudication) Clopidogrel (used to prevent blood clots (thrombi)) Vitamin B12, Cyanocobalamin, Hydroxocobalamin Erlotinib, Dabrafenib, Lapatinib or Pazopanib (for cancer treatment) Clarithromycin (an antibiotic) Methotrexate (for cancer or rheumatoid arthritis treatment) Escitalopram (an antidepressant) Clozapine (for schizophrenia)

Do you understand that healthy eating, reduced alcohol consumption, a healthy body weight and smoking cessation are advisable?

Do you understand that acid reflux treatment supplied through this service can only be used for the short-treatment of gastroesophageal reflux disease (GORD) also known as heartburn/acid indigestion for a maximum of 28 days?

Do you understand that if you experience no relief after 14 days or your symptoms persist after 28 days of treatment you must contact your GP for further diagnosis/treatment?

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 proton pump inhibitors (e.g.omeprazole, pantoprazole, lansoprazole, rabeprazole, esomeprazole)?

Are you breast feeding or pregnant or possibly pregnant?

Do you have any of the following conditions:

Osteoporosis Liver problems Gastric cancer Hypomagnesaemia (low magnesium in the blood)

Have you ever developed a ring-shaped or plaque-shaped rash after sunlight exposure, at a time you have been actively taking a proton pump inhibitor?

Are you aged over 50 with new or recently changed symptoms?

Are you experiencing acid reflux at least twice a week? Symptoms include:

Heartburn - a burning feeling in the chest just behind the breastbone that occurs after eating and lasts a few minutes to several hours Chest pain, especially after bending over, lying down or eating Burning in the throat, or hot, sour, acidic or salty-tasting fluid at the back of the throat Feeling of food "sticking" in the middle of the chest or throat

Are you experiencing any of the following?

difficulty swallowing unintentional weight loss abdominal swelling persistent vomiting severe/persistent diarrhoea vomiting blood blood in your stools or black, tarry stools have iron deficiency anaemia severe liver problems