Simple Online Doctor

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Patient Notice! This questionnaire forms the basis of your gout consultation today. We need you to be honest with your answers including any current medication you are on. This allows our doctors to provide accurate advice and safely prescribe your medication.

1Your Gout

Are you between 30-65 years old? *

NoYes

Unfortunately, you are not a suitable age for an online consultation. Please discuss treatment options with your regular GP.

ID and age verification are required prior to receiving treatment.

Have you previously been diagnosed with Gout by a doctor? *

NoYes

Was a blood test completed to confirm your gout diagnosis? *

NoYes

Please select any other tests the GP carried out to help with the diagnosis *

X-raysIn-person examinationNeedle to the affected jointNone of the above

Have you been prescribed colchicine (Colgout, Lengout) before? *

NoYes

Have you taken colchicine in the past 3 days? *

NoYes

Have you been prescribed allopurinol (Zyloprim) before? *

NoYes

Do you know of any triggers which set off your gout attack? *

NoYes

Please list these below *

Are you having a gout flare up (or attack) now? *

NoYes

Are you confident that you can recognise gout attacks when they happen? *

NoYes

How many gout attacks have you suffered from over the past year *

Is it the same as previous gout attacks you have experienced? *

Which joint(s) are affected by gout *

Please give more information about the joints that are affected *

What symptoms are you currently experiencing? *

What other symptoms are you currently experiencing? *

Do you have a high temperature, multiple swollen or sore joints, nausea, or feel like you cannot eat? *

NoYes

Please provide more information below. *

Have you recently had an accident, fall, or injury around the area which is affected? *

NoYes

Please provide more details *

Select the statements below which are true about your gout *

My joint pain and swelling is only present during an attack and normally takes about 24 hours to reach its peakMy joint pain stiffness is at its worst first thing in the morningMy joint pain and stiffness gets worse upon movement and activityMy joint redness and swelling is always there and never goes away

2Your Health

What gender were you assigned at birth? *

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

NoYes

Are you requesting to order allopurinol? *

NoYes

Are you requesting to order colchicine? *

NoYes

Do any of the following apply to you? *

You have had an allergic reaction to allopurinol in the pastHave a known HLA-B*5801 alleleYou have suffered from hemochromatosisHave severe liver impairmentHave severe kidney impairmentYou suffer from kidney stonesYou have a thyroid conditionNone of the above

Do any of the following apply to you? *

You have had an allergic reaction to colchicine in the pastYou have a blood disorder (such as low platelet count)You have problems with your heart or digestive systemYou are undergoing hemodialysisYou have severe kidney impairmentYou have severe liver impairmentNone of the above

Please provide more information below. *

Are you currently taking any of the following medications? *

Are you currently taking any medications you have not already informed us about? *

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 medications or substances? *

NoYes

Please provide more details. *

Is there any other information you feel would be useful for our clinicians to know about? *

NoYes

Please provide more information below. *

Have you had a blood test by your GP in the past year? *

NoYes

While taking Allopurinol, regular dehydration may result in kidney stones. You must stay adequately hydrated by drinking ~2L of water daily. Do you understand this advice? *

NoYes

Please provide more information below. *

I understand I require a review by my regular GP if the symptoms are changing or worsening. *

NoYes

Please provide more information below. *

I confirm I will only be using allopurinol as prevention for gout attacks and I will not be using this medication to treat an active flare-up *

Confirm

I confirm I will stop using allopurinol if a rash develops and seek medical attention promptly *

Confirm

I acknowledge that using allopurinol will increase my thyroid stimulating hormone (TSH) levels *

Confirm

Are you are aware that you should not take more than 6mg (12 tablets) of colchicine per attack of gout? *

NoYes

Please provide more information below. *

Are you aware that you should not repeat a treatment course of colchicine within 3 days? *

NoYes

Please provide more information below. *

Please confirm you will seek medical help immediately if you experience any of the following after taking colchicine; Nausea or vomiting, stomach pain or diarrhoea, these can be signed of colchicine toxicity. *

Confirm

Please confirm you will seek medical help immediately if you experience any of the following after taking colchicine; a high temperature, swollen mouth, bleeding that does not stop, unusual bruising or rash, these can be signed of a serious problem with your blood. *

Confirm

3Consent

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.

Confirm

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