Acid Reflux & Heartburn

Are you suffering from heaartburn, indegestion or acid reflux currently?

Yes

No

Has a qualified doctor diagnosed your conditon before?

Yes

No

Since when have you struggled with heartburn/acid reflux?

It's my first time

Under a month

Almost a year

Several years

After taking naproxen for Gastric Protection

How frequent do you experience Heartburn/acid reflux?

Once in a while after meals or drinks

Everyday

Every week

After taking naproxen for Gastric Protection

What could be causing your symptoms?

When did you last talk to a General Practitioner about the condition?

Are you a smoker?

Yes

No

Do you take at over 10 alcoholic drinks in a week?
A single alcoholic drink equals: A pint of 4% alcoholic bevarages, 175 ml (medium) wine glass, Twice the level of spirit

Yes

No

Kindly share your weight and height
Height should be above 1 ft 10 inches

Do you have any of these symptoms?

Sleep interruptions caused by heartburns or indigestion

Having a hoarse or sore throat

Constantly coughing or wheezing especially at night

None of the above

Do you fall under any of the following categories
You are above 65 years in age You are 55 years or older and are having the symptoms for the first time in a year or your symproms could be evolving or getting worse You have anaemia, Struggling or having pain when swalowing anything Having unexplainable weight loss You've had bloody vomits, surgery and have battled with gastric ulcers or jaundice Your stool is dark and sticky or you bleed from your rectum (Most specifically a dark blood).

Yes

No

Do you promise to get guidance from your physician in any of these situations?
If your situation changes or worsens If the mediction stops working If you don't feel better within the first five days of medication If the medication causes any advese health effects

Yes

No

Has your physician currently prescribed 20mg tablets for the treatment of indigestion, hertburn or acid reflux?

Yes

No

Do you use any of these medications?
Diazepam for anxiety treatment Phenytoin for epilepsy treatment Glipizide for diabetes treatment Triazolam for insomnia treatment Nelfinavir, Delaviridine or Atazanavir for HIV Anti-inflamatory medication (e.g. asprin, naproxen or ibuprofen) Sucralfate for ulcers Gefitnib for lung cancer Warfarin for blood thinning Lidocaine (An anaesthesia) Theophylline for breathing challenges

Yes

No

Do you struggling with any of these?
Porphyria Stomach Ulcers Cancer of the stomach Issues related to your immune system

Yes

No

Does any of these apply to your use of Femotidine?
You develope allergies or are highly sensitive to Femotidine You develop allergies or are very sensitive to the drug You are treating other conditions not related to heartburn, reflux, or indigestion using the drug

Yes

No

What's your gender?

Male

Female

Transmale (Born a female)

Transfemale (Born a male)

Does any of these describe you?

- You have an underlying medical condition

- You've been through a major surgical procedure You have allergic reactions

- You have cardiovascular conditions or might have had suffered a stroke.

- You suffer from a low liver or kidney function

Yes

No

Are you suffering from heartburn, indegestion or acid reflux currently?

Yes

No

Has your physician currently prescribed the Omeprazole 20mg tablets for the treatment of indigestion, heartburn or acid reflux?

Yes

No

If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option

Presently Pregnant

Presently Breastfeeding

Planning on getting pregnant

Neither Pregnant nor Breastfeeding

Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.

Yes

No

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Acid Reflux & Heartburn

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