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Medical Assessment for Stop Smoking Treatments

Complete this short online consultation so our medical team can show you suitable treatments.

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Tell us about yourself
Are you aged 18 or over? (You must be at least 18 years old to complete this medical consultation and receive treatment.)
About Your Symptoms
Do you think you might be pregnant, or are you currently pregnant or breastfeeding?
Are you, or have you ever had, an allergy or sensitivity to varenicline?
Are you currently experiencing, or have you previously experienced, depression, low mood, anxiety, changes in behaviour, suicidal thoughts, or any other diagnosed or suspected mental health condition?
Are you currently experiencing, or have you previously experienced, any of the following conditions?

Diabetes  inc— luding Type 1, Type 2, or impaired glucose control requiring monitoring or medication.

Heart disease or a history of stroke —  such as angina, heart attack, heart failure, irregular heartbeat, or any cerebrovascular event.

Kidney (renal) disease —  including reduced kidney function, chronic kidney disease (any stage), or past kidney injury.

Seizures or epilepsy —  any history of seizures, diagnosed epilepsy, or medication used for seizure control.

Any serious medical condition requiring urgent or immediate hospitalisation —  for example severe respiratory illness, severe liver disease, uncontrolled high blood pressure, or any condition considered medically unstable.

Your Current Medication
Do you take any medicines at the moment, including prescription treatments, over-the-counter products, herbal supplements, or recreational drugs?
Patient Declaration & Agreements
Do you agree to the following? Please read each statement carefully before confirming. This ensures you understand how your treatment will be supplied and used safely.


☑️ I will read the Patient Information Leaflet provided with my medication before use.

☑️ I will contact ifeelshy and inform my GP immediately if I experience any side effects, start a new medication, or if my medical conditions change during treatment.

☑️ I understand that the treatment is for my personal use only and will not be shared with anyone else.

☑️ I confirm that I have answered all questions accurately and truthfully to the best of my knowledge.

☑️ I understand that the prescriber relies on my answers in good faith, and that providing incorrect or incomplete information could affect my health.

☑️ I understand that while treatment decisions are made jointly between myself and the prescriber, the final decision to issue a prescription rests with the prescriber.

 

Do you understand that varenicline is most effective when combined with your own determination and support from others?
Are you aware that varenicline treatment is initiated with a 2-week starter pack before progressing to the ongoing maintenance dose?
Are you aware that if you experience agitation, low mood, behavioural changes, or suicidal thoughts while taking varenicline, you must stop the treatment and contact your doctor immediately?
Are you aware that you must stop taking varenicline and contact your GP or an urgent healthcare provider immediately if any of the conditions listed below occur?

Allergic or Skin Reactions - sudden rash, hives, blistering, peeling skin, or swelling of the face, lips, throat, or neck (especially if it affects breathing or swallowing).

Breathing or Chest Symptoms - new or worsening shortness of breath, wheezing, chest pain, tightness, or pressure.

Mood, Behaviour, or Mental Health Changes- feeling unusually agitated, low, anxious, irritable, confused, or not yourself, including any thoughts of harming yourself. Seeing or hearing things that aren't there (hallucinations).

Neurological Symptoms - seizures, fainting, sudden dizziness, or loss of consciousness.Sudden weakness, numbness, trouble speaking, or difficulty with coordination.

Heart or Circulation Problems - fast, irregular, or pounding heartbeat, or any new circulation concerns (e.g., cold or painful limbs).

Stomach or Abdominal Symptoms - severe or persistent tummy (abdominal) pain.

Vision Changes - sudden blurred vision, vision loss, or other unexpected visual problems.

Are you aware that stopping varenicline may lead to symptoms such as irritability, increased cravings to smoke, low mood, or difficulty sleeping, as part of nicotine withdrawal?