Consultation - HLP Weight Loss

Genital Herpes

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.

Question 1:Do you have any known allergies?

Question 2:Are you currently taking any medications?

Question 3:Do you have any chronic conditions? (e.g., diabetes, hypertension, asthma, etc.)

Question 4:Have you had any surgeries in the past year?

Question 5:Do you smoke?

Yes

Question 6:Do you consume alcohol?

Question 7:How often do you exercise?

Daily

Weekly

Rarely

Never

Question 8:What is your typical diet like? (e.g., balanced, high-fat, spicy foods)

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.

Question 1:Have you been diagnosed with genital herpes by a healthcare professional?

Question 2:Have you had any tests to confirm the diagnosis? (e.g., viral culture, PCR test, blood test)

Question 3:What symptoms are you currently experiencing? (e.g., sores, blisters, itching, pain during urination, flu-like symptoms)

Question 4:How often do you experience outbreaks? (e.g., monthly, several times a year, rarely)

Question 5:Are there specific triggers that worsen your symptoms? (e.g., stress, illness, certain foods)

Question 6:Have you been prescribed medication for genital herpes before?

Question 7:Are you currently taking any medication for genital herpes?

Question 8:Have you experienced any side effects from your current or past genital herpes medications?

Question 9:Have you tried any non-medication treatments for genital herpes? (e.g., lifestyle changes, dietary adjustments, stress management)

Question 10:Have you tried any non-medication treatments for genital herpes? (e.g., lifestyle changes, dietary adjustments, stress management)

Question 11:Have you used over-the-counter treatments for genital herpes?

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.

Question 1:Understanding of Risks

I have been informed about the potential side effects and interactions of the prescribed medication for genital herpes:

Question 2: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.

Question 3: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.

Question 4: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

Consultation for Genital Herpes