2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3582 0000
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Diarrhoea and Vomiting Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about your symptoms on Patient.info?

    It is advised that you read up about this condition and the related symptoms.

    Yes

    No

    2. Have many episodes have you had in the last 24 hours?

      3. For what duration have you had diarrhoea?

        4. Are you experiencing any of the following:

          		 Blood in your diarrhoea
          Abdominal cramps/pain
          Fever
          Vomiting

          5. Are you aware that you need to drink oral rehydration fluids like Dioralyte to help with your diarrhoea? You can buy this over the counter from your pharmacist.

            Yes

            No

            6. Are you taking regular medication from the following list that may interact with Ciprofloxacin?

            • warfarin or other oral anti-coagulants (to thin the blood)
            • probenecid (for gout)
            • methotrexate (for certain types of cancer, psoriasis, rheumatoid arthritis)
            • theophylline (for breathing problems)
            • tizanidine (for muscle spasticity in multiple sclerosis)
            • clozapine (an antipsychotic)
            • ropinirole (for Parkinson's disease)
            • phenytoin (for epilepsy)
            • pentoxifylline (for circulatory disorders)
            If you are taking regular medicine that interacts with ciprofloxacin you should use azithromycin as an alternative antibiotic.

            Yes

            No

            7. Are you allergic to ciprofloxacin?

              If you are allergic to ciprofloxacin you may be able to take azithromycin as an alternative antibiotic.

              Yes

              No

              8. Have you been diagnosed with any of the following?

              • Myasthenia gravis (Rare muscle disorder)
              • Renal impairment (Kidney disease)
              • G6PD deficiency (Rare blood disorder)
              • Tendon weakness or disorder
              Please see your regular doctor before taking ciprofloxacin or go to consultation for the alternative antibiotic, azithromycin

              Yes

              No

              9. For women, are you intending to take ciprofloxacin when pregnant or breast-feeding?

              • Men should answer 'No'.
              Manufacturer recommends avoidance. We are unable to prescribe ciprofloxacin for you.

              Yes

              No

              10. Are you aware that ciprofloxacin may impair skilled task such as driving?

              • This is an uncommon side effect.
              Ciprofloxacin may impair skilled task such as driving. You can change your answer and continue.

              Yes

              No

              11. Are you aware that ciprofloxacin can cause muscle and tendon pain?

              • Significant but rare side effect requiring Ciprofloxacin to be stopped.
              Ciprofloxacin can cause muscle and tendon damage of which pain is a symptom. You can change your answer and continue

              Yes

              No

              12. Are you aware that Ciprofloxacin can increase sensitivity to sun light?

              • Prolonged exposure to full sun best avoided
              Ciprofloxacin can increase sensitivity to sun light, exposure to which should be reduced whilst taking. You can change your answer and continue.

              Yes

              No

              13. Are you aware diarrhoea symptoms should improve within 24 hours of starting Ciprofloxacin?

              • Worsening symptoms or symptoms not improving require medical attention.
              Worsening symptoms or symptoms not improving require medical attention. You can change your answer and continue.

              Yes

              No

              14. Do all of the following apply to you?

              • I will read the patient information leaflet supplied with my medication.
              • The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
              The conditions must apply for you to be able to use this service.

              Yes

              No

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