Male Patients Form 7

PREVIOUS PRESCRIPTION HAS EXPIRED PRESCRIPTION FOR AN ADDITIONAL PEN If OTHER, please specify:

LESS THAN ONE YEAR BETWEEN ONE YEAR & FIVE YEARS MORE THAN FIVE YEARS

DOCTOR ONLINE DOCTOR CONSULTANT SPECIALIST If OTHER, please specify:

NO If YES, I HAVE, please specify the outcome of this review by your GP:

Yes No

YES NO

Yes If No - having a anaphylactic reaction now, call 999 and explain your situation.

Yes No

NO Tricyclic antidepressants MAOIs Parkinson's treatments Digitalis Quinidine Medicines for heart disease Alpha blockers Beta blockers If other, please specify:

NO Heart disease High blood pressure Overactive thyroid Diabetes Tumour on adrenal gland Glaucoma Reduced kidney function Prostate disease Low potassium levels in blood High calcium levels in blood Asthma If other, please specify:

Yes No

No If YES, I HAVE, please specify:

No If YES, I HAVE, please specify:

No If YES, I HAVE, please specify:

MALE FEMALE

Yes I have clicked the link and uploaded my image as requested No I will upload an image later to the folder linked above I do not have a previous prescription to upload If other, please specify:

I CONFIRM I DO NOT CONFIRM