Asthma

1
Personal Info* This field is required.
First Name
Last Name
Please enter your phone number
Please enter your height(cm)
Please enter your weight(kg)
2
Please insert your date of birth* This field is required.
Date
Day
Month
Year
3
Please insert your Email* This field is required.
example@example.com
4
Are you allergic to any medication
YESNO
5
Please state the medication
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Ok
Ok
6
Are you taking any traditional/recreational medication* This field is required.
YESNO
7
Please state the medication
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Ok
Ok
8
Do you have any chronic medical illness* This field is required.
YESNO
9
Please state your illness
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Ok
Ok
10
Do you smoke* This field is required.
YESNO
11
Please state how many cigarette per day (Pack/day)?Pack / day
12
Please consider to stop smoking.

For further information, please read the following link
13
Have you ever been diagnosed with asthma* This field is required.
YESNO
14
What are your symptoms of asthma* This field is required.
Wheezing
Shortness of breath
Coughing
Others
15
Please specify your symptoms
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Ok
Ok
16
Is your asthma is controlled by medication* This field is required.
YESNO
17
When were you last treated in emergency department
Date
Day
Month
Year
18
Were you given oral steroid
YESNO
19
When did you last talk to your GP about asthma medicationIf over 6 months, please consider booking an appointment with GP
Date
Day
Month
Year
20
Is your asthma affecting your daily activities/ sleep in the past 4 weeks with following symptoms* This field is required.
Daytime symptoms more than twice per week
Any night waking due to asthma
SABA(short acting bronchodilator reliever) is required more than twice per week
Any activity limitation due to asthma
No symptoms in the past 4 weeks
21
Which reliever are you using* This field is required.
Ventolin (Salbutamol)
Others
22
What is your dosage for Ventolin
100 mcg
200 mcg
23
How many puff do you take each time
One puff
Two puff
More than two puff
24
What is the frequency
Used daily
Two/three times per week
Less than once per week
25
Please state the reliever that you are using(please specify the dosage)
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Ok
Ok
26
Which preventer are you using* This field is required.
Please Select
Please Select
Becotide inhaler(Beclometasone) 200mcg
Beclazone inhaler(Beclometasone) 50,100, 250 mcg
Pulmicort turbohaler(Budesonide) 200 mcg
Filxotide Evohaler (fluticasone) 250 mcg
Seretide Diskus(salbutamol 50 mcg/ Fluticasone 100, 250, 500 mcg)
Symbicort(Budesonide 100 mcg/ fomoterol 6 mcg)
Others
27
Please specify your inhaler corticosetroid
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Large
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Small
Ok
Ok
28
How many puff do you take each time
One puff
Two puff
More than two puff
29
What other medications are you using for asthma* This field is required.Please state the medication and its dosage and frequency used. IF no medication, please type None
30
Are you confident with usage of inhaler* This field is required.
YESNO
31
Please read this guideline for the methods of using inhaler, and if you are not confident, please book appointment with GP
YES, I want to make apt with GPNO,I want to continue
32
Do you need pharmacy delivery service?* This field is required.
YESNO
33
Please select the pharmacy that you want for delivery service
Please Select
Please Select
Pure pharmacy Foxrock
Health wave pharmacy dundrum
34
Please select the pharmacy that you want for prescription(If you can't find your pharmacy. Please click "NEXT" to fill your pharmacy)
35
Please kindly provide the name of pharmacy(please leave its healthmail if you know it ).
36
Terms and Conditions* This field is required.Before continuing you must agree to Gpdoc Terms and Conditions
37
I confirm that I have read and understood this and my answers are fully correct and true.* This field is required.
YES. I confirmNO. I don't confirm
38
If you have any feedback for this questionnaire, please write it down(optional)
39
Are you a GMS patient?* This field is required.
YESNO
40
Please kindly book Video/Face to Face Appointment to discuss further.

You can book online at here

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41
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ORDER SUMMARY
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Prescription fee
€35.00Edit
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Total cost €0.00
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42
Please click SUBMIT to submit your questionnaire

What happens after this?
1.) you will receive confirmation via email when your prescription has been sent electronically by your pharmacy selected by you.

2.) You MUST contact the pharmacy upon receiving the confirmation email of prescription to activate the prescription and pharmacy will prepare the prescription for you. You must indicate to pharmacy about collection or delivery.
Pharmacy will advice charges or prescription or delivery accordingly.

Thank you for using this service.
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