Fibromyalgia and Low-Dose Naltrexone consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Where do you typically experience pain? (Check all that apply) *

Neck
Shoulders
Back
Hips
Legs
Arms
Other (please specify):

Please tell us about where you typically feel the pain *

On a scale of 1-10, how would you rate your pain on an average day? (1 = minimal pain, 10 = severe pain): *

How long have you been experiencing chronic pain? *

Do you experience any of the following symptoms? (Check all that apply) *

Fatigue
Sleep disturbances
Stiffness in the morning
Headaches
Irritable bowel syndrome (IBS)
Depression or anxiety
Memory problems (“fibro fog”)
Sensitivity to noise, light, or temperature
Tingling or numbness in hands and feet
Other

What other symptoms are you experiencing *

Do you have trouble falling asleep? *

Do you wake up frequently during the night? *

Do you have low energy levels throughout the day? *

Do you feel rested when you wake up in the morning? *

Do you currently suffer from depression or anxiety? *

Do you feel that your chronic pain has affected your mental health? *

Have you ever sought counseling or psychological support for your condition? *

Does your condition affect your ability to work or perform daily tasks? *

Do you require assistance with daily activities? *

Have you made any lifestyle changes to manage your condition? (e.g., diet, exercise, stress management) *

Are you currently taking any medications for fibromyalgia? *

Please tell us about the medicines you are currently taking for fibromyalgia. *

Have you tried any non-medication treatments (e.g., physical therapy, acupuncture, massage)? *

Are you currently using or have you considered Low Dose Naltrexone (LDN) as a treatment option? *

Have you experienced any of the following? (Check all that apply) *

Unexplained weight loss
Unexplained fevers
Frequent infections
Easy bruising or bleeding
Swollen lymph nodes (lumps in the neck, armpits, or groin).
Recent trauma or injury
Rapid progression of symptoms
New or unusual neurological symptoms (e.g., vision changes, seizures)
Loss of bladder or bowel control
New swelling or redness in joints
None of the above

We’re sorry, but there are no suitable treatments for you.

The safety and well-being of our patients is our number one priority, and based on your answers, we can’t recommend any of our treatment options. We know this is both frustrating and disappointing, but we want to make sure that we’re putting your health first and that you find the right care.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Have you used Low Dose Naltrexone (LDN) before? *

Did you experience any side effects when using LDN? *

Please tell us about the side effects you experienced with LDN *

Do you suffer from liver or kidney disease? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you suffer from poorly controlled type 1 or type 2 diabetes *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Are you currently taking any opioid pain medication? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you suffer from active substance abuse, either with alcohol or drugs? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

What is your biological sex? *

Male
Female

Are you pregnant, breastfeeding, or trying for a baby? *

We’re sorry, but there are no suitable treatments for you.

If you’d like to speak to our clinicians about this, please email info@medicalmojo.co.uk. We’ll do our best to find a solution or recommend some safe next steps.

Note: If you made a mistake in your consultation, you can change your answers

Do you have any other medical conditions not already mentioned? *

Please provide more details *

Are you taking any other medications or do you have any other medical conditions that has not already mentioned? *

Please provide information about any medical conditions you have and the medications you’re currently taking. Include the medication name, dosage, and duration of use.

Other medication *

Do you have any other allergies that you have not previously mentioned? *

Please give us more details on these allergies *

Do you agree and consent to the following?

I am at least 18 years old and live in the UK.
I have the capacity to make decisions about your own healthcare
I shall be the sole user of any medication offered to me through this service.
I confirm all answers are provided by me and are truthful.
You understand the prescriber will take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health
If prescribed a treatment, I will read the Patient Information Leaflet (PIL) that will be provided.
If prescribed a treatment, I will inform my GP of my treatment and contact them if I have any side effects associated with the treatment.
You agree to our terms and conditions, privacy policy and acceptable use policy
You are aware you will be subject to a soft check to validate your identity using LexisNexis.

Checkboxes *

I agree to the statements and give my consent for any treatment provided.

Are you registered with a GP in the UK?

(Optional) Do you consent to us accessing your NHS Summary Care Record (the medical details held by your GP) or requesting further information on your medical history from your GP?

Summary care records

I consent

(Optional) Do you give us consent to write to your GP to share information of this supply and any information we hold about you?

Send information to GP

I consent

Product Category

Important

We review all orders to ensure you receive the best treatment possible. If what you ordered is unsuitable, we will refund part or all of your order.

If we decide that what you ordered is unsafe for you, based on the other information you provided, we won’t provide any treatments. However, we may call you and suggest alternatives.

Fibromyalgia and Low-Dose Naltrexone consultation

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Conditions

Treatments

Care and policies