Long COVID consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

Do you believe you have the mental capacity to make decisions about your own healthcare? *

We’re sorry, but there are no suitable treatments for you. Your symptoms indicate that your condition could be serious and you need to be seen by a doctor immediately. Please go to your local Accident and Emergency department.

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 hello@courierpharmacy.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 experiencing any of the following severe symptoms? (Select all that apply) *

Severe chest pain
Sudden or worsening shortness of breath
Confusion or loss of consciousness
Severe difficulty breathing
New or worsening severe headache
Sudden weakness or numbness on one side of your body
Persistent, extreme fatigue that is not relieved by rest
None of the above

If you’d like to speak to our clinicians about this, please email hello@courierpharmacy.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

Is your fatigue accompanied by any of the following?

Unexplained weight loss
Fever or night sweats
Frequent infections
Easy bruising or bleeding
Bone or joint pain
Swollen lymph nodes (lumps in the neck, armpits, or groin)
None of the above

If you’d like to speak to our clinicians about this, please email hello@courierpharmacy.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 ever tested positive for COVID-19? *

Yes
No
Not sure

If yes, when were you diagnosed? *

How would you describe the severity of your initial COVID-19 infection?

Asymptomatic or very mild
Mild (managed at home)
Moderate (some medical care needed)
Severe (hospitalised)
Very severe (ICU/ventilator)

Do you currently experience ongoing symptoms that you believe are related to COVID-19? *

Yes
No
Not sure

When did these long-term symptoms start? *

Within 1 month after infection
1-3 months after infection
More than 3 months after infection
Not sure

Which of the following symptoms do you currently experience? (Select all that apply) *

Fatigue
Brain fog or difficulty concentrating
Shortness of breath
Chest pain or palpitations
Muscle or joint pain
Headaches
Loss of taste or smell
Sleep disturbances
Digestive issues
Anxiety or depression
Other symptoms

What other symptoms are you suffering from? *

How severe are your symptoms on average? (Scale: 1 = Mild, 10 = Severe)

Selected Value: 0

How often do your symptoms interfere with your daily activities? *

Rarely
Occasionally
Frequently
Constantly

Has a healthcare provider diagnosed you with long COVID? *

Yes
No
Not sure

Have you tried any treatments or therapies to manage your Long COVID symptoms? (Select all that apply) *

Low-Dose Naltrexone (LDN)
Coenzyme Q10 (CoQ10)
Melatonin
Vitamin D
Other supplements or medications
None

Please specify *

If you have tried any treatments, how effective have they been? (Scale: 1 = Not effective, 10 = Very effective)

Selected Value: 0

How has Long COVID impacted your quality of life? (Select all that apply) *

Work or school performance
Social activities
Physical activities
Mental health
Sleep quality
Other

Please select the treatment you would like *

Low-dose naltrexone
Coenzyme Q10
Melatonin

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

If you haven’t used low dose naltrexone (LDN) before, we advise to start with a lower dose and gradually increase until you find the maintenance dose that works for you. So, we usually recommend starting with the LDN oral solution and starting from 0.5ml daily and increasing the dose in 0.5ml increments. Alternatively you can start with a lower dose of the capsules. If you don’t find the dose you need listed, please contact us on hello@courierpharmacy.co.uk info@medicalmojo.co.uk or phone 0203 189 1942 and our compounding team can prepare the dose that’s right for you.

Did you experience any side effects when using LDN? *

Please explain what side effects you experienced *

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 hello@courierpharmacy.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 hello@courierpharmacy.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 hello@courierpharmacy.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 taken coenzyme Q10 before? *

Did you experience any side effects when using coenzyme Q10? *

Please tell us about the side effects you experienced *

Are you taking warfarin? *

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

If you’d like to speak to our clinicians about this, please email hello@courierpharmacy.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 taken melatonin before *

Did you experience any side effects? *

Please tell us about the side effects you experienced *

Do you snore loudly or has anyone noticed you stop breathing during sleep, do you have sleep apnoea? *

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

If you’d like to speak to our clinicians about this, please email hello@courierpharmacy.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 narcolepsy? *

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

If you’d like to speak to our clinicians about this, please email hello@courierpharmacy.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 any of the following:

Significant liver or kidney problems
Autoimmune disease (e.g. rheumatoid arthritis, SLE)
Have a history of seizures or epilepsy.

Melatonin red flag condition *

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

If you’d like to speak to our clinicians about this, please email hello@courierpharmacy.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 take any of the following medications:

Fluvoxamine (an antidepressant)
Benzodiazepines e.g. Diazepam, Lorazepam
Zaleplon, Zolpidem and Zopiclone
Quinolone antibiotics, such as ciprofloxacin
Cimetidine

Melatonin red flag medicine *

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

If you’d like to speak to our clinicians about this, please email hello@courierpharmacy.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 hello@courierpharmacy.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 they’re the best treatment we can offer you. If what you ordered is unsuitable, we will refund part or all of your order.

If we decide what you ordered is unsafe for you, given the other information you provided, we won’t issue any treatment. However, we may call you and suggest alternatives.

Long COVID consultation

Do you agree and consent to the following?

Conditions

Treatments

Care and policies