Consultation - Welcome Pharmacy

Anxiety

Please fill out the form below so that our clinicians can determine if the treatment will be suitable for you to take.

1 About Your Health

Your health and safety are our top priorities. Please provide accurate and complete information during your consultation so we can recommend the most appropriate treatment for you.

Do you have any known allergies?

Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

If yes, please detail them here, otherwise please type N/A

Are you currently taking any medications?

If yes, please detail them here, otherwise please type N/A

Have you had any surgeries in the past year?

If yes, please detail them here, otherwise please type N/A

Do you smoke?

Do you consume alcohol?

If yes, how much a day/weekly?

How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Please provide accurate and honest details during your consultation. This helps us offer the safest and most effective treatment for you.

Who diagnosed your anxiety? (e.g., psychiatrist, general practitioner)

Please provide more detail here

How long have you been experiencing anxiety symptoms?

Please provide more detail here

Have you had any recent tests or assessments to evaluate your condition? (e.g., psychological evaluation, blood tests)

How often do you experience anxiety symptoms? (e.g., daily, weekly, occasionally)

Daily

Weekly

Occasionally

What are the common symptoms you experience? (e.g., excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances)

Please provide more detail here

Are your symptoms triggered by specific situations or events? (e.g., social situations, work-related stress)

Have you been prescribed medication for anxiety before?

Are you currently taking any medication for anxiety?

Have you experienced any side effects from your current or past anxiety medications?

Have you tried any non-medication treatments for anxiety? (e.g., therapy, mindfulness, exercise, dietary changes)

Have you consulted with a healthcare provider about your anxiety?

3 The Agreement and Consent

Please read the Agreement and Consent statements carefully during your consultation. They contain important information to help you stay informed and safe throughout your treatment.

Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for Anxiety.

Medical Guidance

I agree to consult with my healthcare provider before starting any new medication.

I understand that the information provided in this assessment will be reviewed by a licensed pharmacist before my order is processed.

Consent to Share Information

I consent to my personal and medical information being used to assess my suitability for the prescribed medication.

I understand that my information will be kept confidential and used solely for the purpose of this assessment.

Confirmation

I confirm that the information provided in this assessment is accurate and complete to the best of my knowledge.

I understand that providing false information may result in my order being cancelled and may have health implications.

1 About Your Health
2 About Your Condition
3 The Agreement and Consent

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Assessment for Anxiety

Anxiety

1 About Your Health

Do you have any known allergies?

Yes

Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Yes

Are you currently taking any medications?

Yes

Have you had any surgeries in the past year?

Yes

Do you smoke?

Yes

Do you consume alcohol?

Yes

How would you describe your typical diet? (e.g., balanced, high-fat, spicy foods)

How often do you exercise? (e.g., daily, weekly, rarely, never)

2 About Your Condition

Who diagnosed your anxiety? (e.g., psychiatrist, general practitioner)

How long have you been experiencing anxiety symptoms?

Have you had any recent tests or assessments to evaluate your condition? (e.g., psychological evaluation, blood tests)

Yes

How often do you experience anxiety symptoms? (e.g., daily, weekly, occasionally)

What are the common symptoms you experience? (e.g., excessive worry, restlessness, fatigue, difficulty concentrating, irritability, muscle tension, sleep disturbances)

Are your symptoms triggered by specific situations or events? (e.g., social situations, work-related stress)

Yes

Have you been prescribed medication for anxiety before?

Yes

Are you currently taking any medication for anxiety?

Yes

Have you experienced any side effects from your current or past anxiety medications?

Yes

Have you tried any non-medication treatments for anxiety? (e.g., therapy, mindfulness, exercise, dietary changes)

Yes

Have you consulted with a healthcare provider about your anxiety?

Yes

3 The Agreement and Consent

Understanding of Risks

Medical Guidance

Consent to Share Information

Confirmation

Assessment Progress

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