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.

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Born male
Born female



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This may be to any medicines or other substances e.g. peanuts/soya)


Either prescribed (eg. oral asthma tablets) or over the counter, including herbal remedies and supplements or recreational drugs.

 


  • Heart conditions (cardiovascular disease) such as
    • arrhythmias,
    • susceptibility to prolonged QT-interval
    • hypertension
  • Hypokalaemia
  • Hyperthyroidism
  • Diabetes

If yes, please state the date.


Well controlled - using your salbutamol inhaler less than 4x a week




Please see below for the correct technique

https://www.asthmaandlung.org.uk/living-with/inhaler-videos

 





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  • This treatment is solely for your own use
  • You will read the manufacturer’s patient information leaflet and stop and report and adverse effects immediately to the relevant healthcare professional
  • You confirm that you have answered all the above questions accurately and truthfully. You understand our team take your answers in good faith and base their decisions accordingly, and that incorrect information can be hazardous to your health.

Please ensure the medication is stored safely out of reach of young children or pets to prevent accidental ingestion.