Asthma Prescription

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Do you agree and consent to the following?

You are completing this consultation for yourself and to the best of your knowledge.
You will disclose any medical conditions, serious illnesses or operations you have had.
You will disclose any prescription medications you are currently taking and agree to use only one weight loss treatment at a time.
You agree to our Terms & Conditions, Terms of Sale, and confirm that you have read our Privacy Policy.
Your accurate and honest responses to this online questionnaire for weight loss treatment are crucial. Withholding or providing false information can severely harm your health and may result in life-threatening consequences. By filling out this questionnaire, you confirm that your responses are truthful and accurate, acknowledging the potential risks of misinformation.
You agree to undergo identification and age verification. This may require submitting valid documents to our approved third-party verification partner for validation.
You consent to EveryDayMeds accessing your Summary Care Record (SCR) for the purpose of ensuring the safe supply of treatment. If the SCR is unavailable or incomplete, you agree to participate in appropriate two-way communication (e.g. phone, secure message, or video consultation) to verify your medical history. If you do not respond or engage, your order will be cancelled.

Asthma Assessment

The following questions are the Asthma Control Test (ACT) and they will help us work out whether your asthma is currently well-controlled.

During the past 4 weeks, how much of the time has your asthma kept you from getting as much done at work, college or home?

All of the time Most of the time Some of the time A little of the time None of the time

During the past 4 weeks, how often have you had shortness of breath?

More than once a day Once a day 3 to 6 times a week Once or twice a week Not at all

During the past 4 weeks, how often have your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) woken you up at night or earlier than usual in the morning?

4 or more nights a week 2 or 3 nights a week Once a week Once or twice Not at all

During the past 4 weeks, how often have you used your rescue inhaler or nebuliser medication (such as salbutamol/albuterol)?

3 or more times per day 1 or 2 times per day 2 or 3 times per week Once a week or less Not at all

How would you rate your asthma control during the past 4 weeks?

Not controlled at all Poorly controlled Somewhat controlled Well controlled Completely controlled

Your Asthma Control Test Score: 0 / 25

Your Health

Are you aged between 18 and 65?

Yes No

Have you been diagnosed with asthma by a GP or hospital specialist?

Yes No

Do you know how and when to use your inhaler(s)?

Yes No

Have you had any of the following in the last 12 months due to asthma or breathing problems?

Emergency hospital admission
Required ambulance care
Emergency room treatment

Yes No

Are you currently smoking, vaping, or using shisha?

Yes No

Are you pregnant, breastfeeding, or planning to become pregnant in the next 6 months?

Yes No

Do you have any of the following medical conditions?

Overactive thyroid
Irregular or fast heartbeat (e.g. atrial fibrillation, tachycardia)
Angina or heart disease
High blood pressure

Yes No

Have you had any allergic reaction or side effects from any asthma inhaler?

Yes No

Medical Condition

Do you use a blue "reliever" inhaler (e.g. Ventolin, Salamol, Bricanyl, Atrovent) more than 4 times per day?

Yes No

Do you use a regular “preventer” inhaler that contains a steroid? (e.g. Clenil Modulite, Qvar, Flixotide, Pulmicort)

Yes No

Are you currently following a MART or AIR regime (Maintenance and Reliever Therapy)? (e.g. Fostair, Symbicort used both daily and when needed)

Yes No

Has your asthma been reviewed by a GP or nurse in the last 12 months?

Yes No

Medication

Are you currently taking any of the following?

Heart medications (e.g. propranolol, amiodarone, digoxin)
Terbutaline (e.g. Bricanyl)
Montelukast tablets
Oral steroid tablets
Theophylline (e.g. Uniphyllin)
Injectable biologics for asthma
Diuretics ("water tablets")
Recreational drugs

Yes No

Agreement

Do you understand that you must seek medical help if your symptoms do not improve within 1 hour of using your reliever inhaler?

Yes No

Do you agree to the following?

The information you’ve provided is accurate
It will be used to assess your suitability for treatment
You understand that giving inaccurate information could result in unsafe treatment

Yes No

Do you agree to all of the following?

You will read the patient information leaflet for your inhaler
This treatment is for your personal use only
If you’ve been prescribed more than 3 reliever inhalers in the last 12 months, you’ll have a review with your GP
If you require more than 8 puffs in 24 hours, you will seek urgent medical attention
You will seek urgent help in the event of an asthma attack (e.g. wheeze, chest tightness, breathlessness not relieved by usual inhalers)
You consent to us sharing relevant information with your GP, and for your GP to share information with us
You will inform your GP and our team if you experience side effects or start any new medications

Yes No

Do you give us permission to access your NHS Summary Care Record or request medical history from your GP if required?

Yes No

Do you consent to us sharing relevant consultation details with your GP to ensure continuity of care?

Yes No

GP Consultation

We can notify your GP of your treatment for you. To do so, we need their contact information. Sharing this information allows your GP to maintain a comprehensive record of your medical history, which is crucial for your health. Without complete records, there could be potential risks to your well-being.

I consent to EveryDayMeds contacting my GP and share information about my prescription.

Yes No

Practice/GP Name

Practice/GP Address

Identity Verification

Please upload your identification documents.

Would you like to upload documents now?

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What you need to upload

To safely prescribe weight-loss medication, our clinicians need to verify your identity and assess your eligibility. Please upload both of the following:

Photo ID

Upload a clear photo of one valid ID document, such as:

Passport
UK driving licence
National ID card

Requirements:

The full document must be visible
Text and photo must be clear and readable
The ID must be valid (not expired)

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Tap to upload ID card

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Full-Body Photo

Take a full-body photo of yourself using your camera.

Photo guidelines:

Full body visible (head to feet)
Wear fitted clothing (no coats or baggy clothes)
Stand straight, facing the camera
No filters or edits

This photo is used only to help our clinicians assess your BMI and suitability for treatment.

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Take photo using camera

Camera required

Upload Previous Prescription

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Upload previous prescription

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If you select this option, your order won’t be approved until all required documents are submitted. After your consultation, we’ll email you instructions on how to upload your documents.

Your Asthma Prescription Plan

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