About your condition and treatment
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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Are you experiencing nausea?
Do you realize that if you are unable to consume fluids normally, it is critical to avoid dehydration by drinking little sips of water frequently?
Do you conscent to seeking immediate medical assistance should you suffer the following?
Tummy pain that comes on suddenly.
How frequently do you experience nausea?
Please select your option
Are you experiencing the following?
Have you been vomiting for more than two days?
Do you experience different symptoms other than the ones listed above?
Kindly identify some of the symptoms you experience
You can select more than one option
Has a certified medical practitioner examined about your nausea?
If so, please tell us what they said caused your nausea.
Have you any idea on what could be causing your Nausea?
Notably, if you are unsure about the reason for your nausea, we urge that you visit your doctor for a thorough examination.
For which duration have you been experiencing nausea?
Do you have a history of using Prochlorperazine tablets before?
If yes, how successful was it?
Are you experiencing the following conditions?
Epilepsy.
Can you relate to any of the following?
You have an underlying medical condition
Can you relate to any of the following?
Your hair loss started recently, and you've lost a lot of hair in less than four weeks.
Hair loss has occurred in irregular spots on your head.
Your scalp is itchy or inflamed.
You've lost your hair as a result of your pharmacological treatment.
You're completely bald or have lost all of your body hair.
Did you know that?
If your condition does not improve after four weeks, you should consult a doctor.
Can we share this information with your General practitioner?
Providing us with your physician's address means that you allow us to share this information with him/her for updated medical records if need be. It also allows our clinician to access your medical records if there is a need for that. We advice you share this treatment with your doctor for him/her to update your medical records.
Are you currently receiving any treatment or under any medication?
Please provide more information of the medication being used if any.
If female or transmale, are you currently pregnant, breastfeeding or planning to do so?
Please select your option
What is your biological gender?
Please select your option
Are you currently suffering from nausea (feeling sick) and vomiting (being sick)?
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Do you have a medical history of any of the following?
Renal / kidney problems, Liver problems, Seizure disorders (e.g. epilepsy), Parkinson's disease, Adrenal gland tumour, Methaemoglobinaemia (abnormal blood pigment levels), NADH cytochrome-b5 deficiency, Porphyria, Neurological problems
Do you have any heart problems or QT interval prolongation?
If yes, please provide details
Do you have bleeding, obstruction or a tear in your stomach or gut?
Do you have high blood pressure?
Have you been through menopause?
Do you have asthma, eczema or rhinitis?
Do you suffer from migraine attacks every day?
Have you had a serious reaction or intolerable side effects to metoclopramide or any other medications before?
If yes, please describe the product and the reaction
Women only: Are you breast feeding?
If male, select No.
Do you have any allergies?
If yes, please provide details
Have you been told by your doctor you have an intolerance to any sugars (e.g galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?
If yes, please provide details
Do you have any problems with the levels of salts in your blood (electrolyte imbalance)?
Do you have a current or previous history of depression, suicidal thoughts, generalized anxiety disorder or any other psychiatric disorder?
Has anyone in your close family died suddenly of heart problems?
Has your doctor told you that you suffer from migraines?
Please provide details in this box here...
Are you a heavy smoker, or do you use nicotine substitution therapies?
Have you ever had tardive dyskinesia (involuntary muscle spasms) when taking a medicine?
If yes, please provide details
Please list all your current prescription medication including any medication you buy over the counter...
Please provide details of any recent or past medical history of note
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