Treatment Questions – Your Chemists

Are you aged between 18 and 65?

Yes No

Have you been diagnosed by your GP, nurse or pharmacist with cold sores (herpes labialis)?

Yes No

Do you have any of the following symptoms:

Yes No

Do you have an allergy (hypersensitivity) to medicines containing Aciclovir or Valciclovir or Famacilovir or Penciclovir?

Yes No

Are you pregnant, breast feeding or possibly pregnant?

Yes No

Have you been diagnosed with any of the following conditions?

Yes No

Are you currently taking any medication (including over the counter, prescription or recreational drugs)?

Yes No

Are you taking any of the following medications?

cimetidine (used to treat peptic ulcers)
probenecid (used to treat gout)
raloxifen
medicines that suppress your immune system (e.g. mycophenolate mofetil; ciclosporin; tacrolimus; methotrexate)
theophylline and aminophylline (used in asthma and other breathing problems)
zidovudine (used in HIV infection)
any medicine which affects the kidneys, including aminoglycosides, organoplatinum compounds, iodinated contrast media, pentamidine, foscarnet

Yes No

Do you understand that outbreak treatment should be initiated at the earliest symptom of a cold sore eg tingling, itching or burning sensation?

Yes No

Do you understand that if your symptoms are getting worse and the sores have not healed after 10 days you must see your doctor?

Yes No

Do you agree to the following?

You will read the patient information leaflet supplied with your medication
You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
The treatment is solely for your own use
You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.

Yes No

Cold sores