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.

Have you had a serious reaction to a varenicline before?
If yes, please describe the product and the reaction

Yes

Women only: Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant?

Yes

Do you have any allergies?
If yes, please provide details

Yes

Do you understand that you must seek prompt medical advice if you develop agitation, depressed mood, or suicidal thoughts whilst taking varenicline?

Yes

Do you feel sufficiently motivated to quit smoking (willing to set a quit date between days 8 and 14 of starting treatment)?

Yes

Have you received advice from a smoking cessation counsellor before?
If yes, please provide details

Yes

Have you tried to quit using nicotine replacement therapy (NRT) before?

Yes

Are you on any medicines? Such as antiepileptics, antidepressants, antipsychotics, B-blockers, type 1C antiarrhythmics, cimetidine, theophylline or warfarin?

Yes

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?

Yes

Do you understand that varenicline may affect your ability to perform tasks that require judgement or motor and cognitive skills?

Yes

Do you agree to receive weekly face-to-face motivational support for the first four weeks at least?

Yes

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

Ear Health

Weight Management

Male Health

All Conditions

Quit Smoking

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Ear Health

Weight Management

Male Health

All Conditions

Quit Smoking

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