Simple Online Doctor

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Patient Notice! This questionnaire forms the basis of your acid reflux consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medicinal information provided before selecting your treatment.

1Your Condition

Do any of the following symptoms apply to you? select all that apply: *

Are you experiencing any other symptoms? *

NoYes

Please tell us a bit more about your symptoms and why you require treatment *

How often do you experience symptoms of acid reflux? *

Please tell us a bit more about how often you experience symptoms of acid reflux *

Have you tried any medicines for acid reflux before? *

NoYes

Please tell us what you have tried here: *

Have you ever seen a doctor (or other healthcare professional) about your acid reflux symptoms? *

NoYes

Please tell us a bit more; how long ago did you see a doctor? Did they carry out further tests? *

It is important to see your GP if your symptoms do not resolve or get worse, this is to ensure that your GP can carry out any further investigations to establish the cause of your discomfort and ensure other conditions can be ruled out.

Do any of the following apply to you?

Jaundice
Anaemia
Unintentional weight loss
Difficulty or pain upon swallowing
Previous gastric ulcer or surgery
Vomiting, particularly if there is blood in the vomit
Unexplained appetite loss
Diarrhoea
Age 45 or over with the new onset of symptoms
Age 45 or over where symptoms are worsening
Over 60 years old with abdominal or back pain
Over 60 years old and feeling thirsty all the time, urinating frequently, and/or losing weight

NoYes

Please provide more information below. *

I understand this online service is for repeat supplies only for acid reflux medicines, and that all recurring acid reflux/heartburn symptoms should be assessed by your GP the first time they appear. *

NoYes

Please provide more information below. *

I understand that any acid reflux medicine prescribed by Simple Online Doctor is for occasional use only, and if my acid reflux symptoms do not improve within 5 days of treatment I need to see my regular GP? *

Confirm

I understand I require a review by my regular GP if the symptoms are changing or worsening or if symptoms are not controlled by taking treatment two to three times a week. *

Confirm

Do you understand that persistent acid reflux can be the result of serious underlying medical conditions and the cause must be assessed on a regular basis with your GP? *

NoYes

Please provide more information below. *

2Your health

Are you currently taking any prescription-only medicines, alternative medicines or recreational drugs? Please note that some acid reflux medications can result in your regular medicine not being absorbed fully, potentially causing harm. *

NoYes

Please list any prescription, over the counter or alternative medicines you are taking, including the dose. *

Do you have any known allergies to any medicine or substances? *

NoYes

Please provide more information below. *

Do you have any other health problems or conditions that you think we should know about? (e.g. Myasthenia Gravis, any enzyme deficiencies or recent major operations etc.) *

NoYes

Please provide more information below. *

Are you pregnant or planning to become pregnant or breastfeeding? *

NoYes

Please provide more information below. *

3Your consent

I confirm I am over 18 years old.

The medicine ordered is for my sole use only.

I will read the patient information leaflet supplied with the medicine specifically the side effects and dosages.

I take responsibility to inform my own regular doctor of the online consultation or any changes in my circumstances.

I agree to the Simple Online Doctor terms and conditions. *

Confirm

We strongly advise that you inform your GP of any treatment you receive.
Would you like us to inform them on your behalf? If you are unsure, you can search your GP clinic information by clicking here.

NoYes

Please enter the email address of your GP clinic *

As per Australian telehealth guidelines, all first time patients, those requesting a new treatment or those looking to renew a prescription must have a brief video or phone call with one of our doctors. Do you have reliable access to the internet on a device which you can use to have a video conversation with our doctors? *

NoYes

You require reliable access to the internet on a device which you can use to have a video consultation with the doctor in order to be suitable for telehealth. Please refer to your regular GP in person.

During your consultation, our doctor will assess whether you are suitable for treatment. If you are, a prescription will be provided to and filled by our pharmacy partner and delivered to your chosen address. Any and all resupplies will be stored on your account and will be available for request from our service when required. For resupplies you will only need to pay for the medication and shipping, you will not be charged a consultation fee. Please confirm you understand this information. *

Confirm

If we are unable to assist via a telehealth consultation, you may be asked to seek alternative medical care such as that of a doctor in person. If this occurs you will receive a refund on your request.

Simple Online Doctor is a private clinic; the consultation and medication may be eligible for rebates through your private health cover, but are not covered by Medicare or the PBS. We conduct regular price reviews to ensure we are providing among the best value online.

Did you have difficulty understanding the English that is written in this assessment, affecting your ability to provide accurate answers or do you require language interpretation during a verbal consultation? *

NoYes

As you have difficulty understanding the assessment and or require interpretation services, you will be required to have an interpreter with you during your consultation with the doctor. You can access these services at Translating and Interpreting Services. Please confirm that you agree to organise an interpreter for your consultation.

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