Medical Questionnaire: Aciclovir

Medical Questionnaire

Prophylactic treatment of Aciclovir 200 mg tablets to help reduce the risk of cold sores
Personal details
Name*

PrefixFirst NamesLast Name
Date of Birth*

DayMonthYear
Age*
Email*
Phone Number*
Medical history
How often have you experienced cold sore outbreaks in the past year?*

Fewer than 6 episodes6 episodes or more
Are you pregnant or breast feeding?*

YesNo
Do you have any of the following conditions?*

Kidney or liver conditionsHIVAny other condition reducing your immune system, like such as recent chemo or radiotherapyNone of the above
Other than those already mentioned, do you have any other significant medical conditions or illnesses?*

Yes (give details below)No
Are you taking any prescription-only medicines or over-the-counter medicines?*

Yes (give details below)No
Please list any medication you are currently taking
Do you have any known allergies?*

Yes (give details below)No
Please list any allergies you have
About Aciclovir 200mg Tablets
Is it suitable for me?
- Taking aciclovir prophylactically, can reduce the risk of getting a cold sore outbreak following your treatment at Elements Medical.
- Taking aciclovir when a cold sore errupts can reduce the severity and length of your outbreak.
- You cannot take aciclovir if you’re pregnant, breastfeeding or have a severe kidney disease.
- Aciclovir doesn’t cure cold sores, but can help reduce how long your outbreak lasts and how bad it gets.
How it works
- Aciclovir is an antiviral medicine.
- It doesn’t cure cold sores but works by stopping the virus that causes cold sores from coming back.
How to use it
- Take one 200mg tablet five times a day for five days.
- If you have been prescribed treatment to help 'prevent' a cold sore because of a procedure you have booked with us, you should start treatment 2-days before your procedure (procedure day being day 3 of your treatment), and continue taking your aciclovir for a further 2 days afterwards.
- Swallow the tablets whole with plenty of fluid. You can take them with or without food.
- Make sure to stay well hydrated while you’re taking this medicine.
What else should I know?
- Aciclovir can sometimes cause side effects such as abdominal pain, diarrhoea, dizziness, fatigue, fever, headaches, nausea, skin sensitivity to the sun, skin reactions, and vomiting.
- Mostly, these are mild and will get better by themselves, but if you’re worried, you can talk to us.
- if you DO get a cold sore, do your best not to touch open cold sores as this can cause them to spread to other parts of your body.
- Other steps you can take during treatment is to avoid oral sex and kissing, until the cold sores have healed.
Consent to treatment
- I have read and understood all the information above.
- I have given truthful answers to all questions, and I undestand that giving misleading responses may put my health at risk.
- I consent to treatment of Aciclovir 200mg if I am found to be suitable.
Date*

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Signature*

Clear
Treatment details
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Expiry date

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Date of treatment

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Medical Questionnaire

Personal details

Medical history

About Aciclovir 200mg Tablets

Is it suitable for me?

How it works

How to use it

What else should I know?

Consent to treatment

Treatment details