IBS

Are you aged 18–65?

Have you been diagnosed with irritable bowel syndrome?

Have your symptoms changed significantly since diagnosis or within the last six months?

Are you experiencing any of the following?

• unintentional weight loss
• abdominal swelling
• nausea and vomiting
• severe/persistent diarrhoea
• severe constipation
• blood in your stools or black, tarry stools
• loss of appetite
• looking pale and feeling tired
• fever
• abnormal vaginal bleeding and/or discharge
• difficulty or pain passing urine

Are you allergic or sensitive to medicines used to treat IBS e.g. Mebeverine, Colpermin (peppermint oil), Alverine, Buscopan (Hyoscine)?

Are you allergic or sensitive to lactose or peanut oil?

Do you have trouble tolerating or digesting sugars, or suffer from galactose or fructose intolerance, total lactase deficiency, sucrose-isomaltese insufficiency or glucose-galactose malabsorption?

Are you breastfeeding, pregnant or possibly pregnant?

Do you have any of the following conditions?

• paralytic ileus (paralysis of the intestinal muscles) or an intestinal obstruction
• inflammatory bowel disease such as ulcerative colitis or crohns disease
• food poisoning or gastroenteritis
• kidney disease
• liver disease
• thyroid problems
• epilepsy
• bladder or bowel obstruction
• treatment for severe sweating
• myasthenia gravis
• bowel cancer
• angle closure glaucoma
• prostate problems
• tachycardia (a fast heart rate)
• an overactive thyroid

Are you currently taking Lomitapide?

Do you understand that healthy eating, reduced alcohol and caffeine consumption, a healthy body weight and not smoking can help to reduce the symptoms of IBS?

Please confirm you are not taking any recreational drugs such as cannabis whilst using IBS medication?

Do you understand that if you experience no relief after 14 days you should contact your GP for further advice?

Some medications may affect performance of skilled tasks by causing drowsiness and dizziness. Do you agree to not drive or operate machinery if you're experiencing these side effects?

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."