Cold Sores

About the Condition and Treatment

To help us understand that this treatment is the right option for you, please answer the following questions. If you get stuck or need any help, you can contact us.

Are you aged between 18 and 65?

Yes

Have you been diagnosed with cold sores by your GP?

If NO, please provide us information about your cold sores.

Yes

Do your cold sores appear only around your mouth and lips?

If NO, please provide information about the affected area.

Yes

Do you suffer any symptoms

- Mouth ulcers /lumps lasting more than 3 weeks

- Painful red and white patches on the inside of the mouth

- Fluid filled blisters/crusts on the lips

Yes

Please upload a picture of your cold sores, if possible.

Only .jpg, .jpeg, .png, and .gif formats are allowed.(10MB file size limit)

About you health

Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Yes

Have you used Aciclovir tablets to treat a herpes outbreak before?

If YES, are they effective?

If NO, what treatment did you use to treat your previous outbreak?

Please provide inforamtion in the type box.

Have you been diagnosed with any of the following conditions?

- Liver problems

- Kidney problems

- Any condition affecting the immune system i.e. cancer, HIV etc

- Nervous system abnormalities

- Electrolyte abnormalities

- Any serious medical condition which may require immediate hospitalisation

Yes

Are you taking any of the following medicines:

- Cimetidine (to treat excess stomach acid).

- Probenecid (to treat gout).

- Mycophenolate mofetil or ciclosporin (used in transplant patients).

- Theophylline (to treat asthma or breathing problems).

- Zidovudine (to treat HIV).

Yes

Do you suffer from any allergies?
If you do, kindly explain them below

Yes

Acknowlegdements

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

Yes

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

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

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