About the 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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Have you had a serious reaction to a varenicline before?
If yes, please describe the product and the reaction
Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?
Women only: Are you breast feeding?
If male, select No.
Do you have any allergies?
If yes, please provide details
Do you understand that you must seek prompt medical advice if you develop agitation, depressed mood, or suicidal thoughts whilst taking varenicline?
Do you feel sufficiently motivated to quit smoking (willing to set a quit date between days 8 and 14 of starting treatment)?
Have you received advice from a smoking cessation counsellor before?
If yes, please provide details
Have you tried to quit using nicotine replacement therapy (NRT) before?
Are you on any medicines? Such as antiepileptics, antidepressants, antipsychotics, B-blockers, type 1C antiarrhythmics, cimetidine, theophylline or warfarin?
Do you have a medical history of any of the following: renal / kidney problems, psychiatric illnesses (with symptoms of irritability or depression), myocardial infarction (MI) or risk factors for MI?
Do you understand that varenicline may affect your ability to perform tasks that require judgement or motor and cognitive skills?
Do you agree to receive weekly face-to-face motivational support for the first four weeks at least?
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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