Narcolepsy

Have you seen your GP about your condition?

Are you pregnant, breast feeding or intending to become pregnant?

Is your GP aware that you intend to take this medication and will you inform your GP that we have issued you with this medication?

Have you been prescribed this before?

Have you been diagnosed with Narcolepsy?

Can you confirm that you have had your ECG (heart tracing) checked before you started this medication?

Are your intentions to use this medication on a short-term basis?

Are you currently taking any form of Hormonal Contraception or Hormone Replacement Therapy (HRT)?

Have you ever had an addiction to medicines/drugs?

Are you aware this medication is potentially addictive with the risk of causing both physical and psychological dependence with regular use?

Do you intend to take this medication with alcohol in your system?

Have you been diagnosed with any of the following? • Kidney, Liver, or Heart problems • High Blood Pressure (>140/90) • Mental Health Problems (eg depression, anxiety, suicidal thoughts)

Are you taking any of the following medications?

• Antiepileptic

• Antifungal e.g. Terbinafine, Ketoconazole

• Chemotherapy or related cancer drugs

• Clarithromycin or Rifampicin (types of antibiotic)

• HIV medications

I agree to the following:

• I will read the patient information leaflet supplied with my medication

• I will contact my GP or MyMedsUK if I experience any side effects

• The treatment is for my use only • I have answered the assessment questions truthfully and accurately

• I agree to the Terms and Conditions and I confirm that I am over 18 years old

• I am aware that I may be contacted to give further information via phone or email and if I am not contactable this will lead to a delay in receipt of my prescription