Valtrex
Valtrex
(generic name: valacyclovir) is indicated for the treatment of initial episodes
of genital herpes. Also indicated
for the treatment of suppression of recurrent genital herpes. Also can be used in the treatment of herpes zoster (i.e.,
shingles).
[Again,
we’ll present the medical history, which is the same as previous
consultations, regarding sex, date of birth, age, height, weight, name, date,
etc.]
Always, on every section:
List all
current prescription medications:
List all
over the counter drugs you may be taking, and why:
List all
known allergies to medications:
Do you
smoke? (yes or no)
Have you had
a complete physical exam within the last two years? (yes or no)
Have you
ever had any type of transplants, such as kidney, heart, lung, or bone marrow?
(yes or no)
Are you
currently on dialysis? (yes or no)
If female,
are you pregnant or presently breastfeeding?
(yes or no)
Do you
consume more than two alcoholic beverages per day?
(yes or no)
Current
medication conditions and past medical history:
Do you currently have or have you ever had any of the following
conditions:
An Endocrine Disorder
Diabetes
Heart Disease
Anxiety
Bone Marrow Transplant
Depression
HIV
Kidney Dialysis
Renal Failure
Sickle Cell Anemia
Kidney Transplant
Seizures
Heart Attacks
Stroke
Depression
Thyroid Disease
High Blood Pressure
Coronary Artery Disease
Compromised Immune System Disease
Organ Transplants
Leukemia
Liver Disease
Kidney Disease
Are you currently being treated for Cancer?
(yes or no)
If yes, please explain:
Have you had surgery in the last six weeks to three months?
(yes or no)
If yes, please explain:
Do you
consider anything in your past medical history to be relevant regarding the use
of Valtrex as a prescription drug?
Family
History:
Do
any of the immediate members of your family any of the following medical
problems, such as:
Cancer
Arteriosclerosis
Stroke
Heart Disease
Gall Bladder Disease
Liver Disease
Blood Pressure Problems
Kidney Disease
Diabetes
Your genital
herpes history:
Have you been diagnosed with herpes by a physician in the past?
(yes or no)
Have
you been examined and had a positive herpes test by your doctor in the past?
(yes or no)
Have you been treated for herpes in the past?
(yes or no)
How
frequent are your recurrent herpes outbreaks (i.e., how many outbreaks do you
have a year)?
Please list
the types of treatment you have received for herpes in the past:
How old were
you when you were first diagnosed with herpes?
Do you wish
now to be treated for a current outbreak or long term suppressive treatment for
ongoing outbreaks? (please check
one)
Please list
a brief description of your outbreaks regarding frequency, severity, and
duration:
Also, whether they have increased or decreased in the last year:
[We’ll refer to personal payment information,
which is no different than the previous ones]
I understand
that Valtrex is contraindicated in anyone under the age of 18 or with advanced
HIV disease. Also, in anyone who
has received a bone marrow transplant, kidney transplant, or any organ
transplant, any patient that is currently in renal failure, or has compromised
renal function or kidney disease or any type of compromised immune system.
I further understand that pregnant and nursing mothers should not use
Valtrex.
I assert
that I am not pregnant or nursing at this time:
I agree and
understand that I must have been positively diagnosed in the past to receive
treatment for genital herpes, and I agree to inform all physicians involved in
my care that I am currently taking Valtrex as a treatment.
I further assert that I have no contraindications to taking Valtrex or
undergoing this therapy. I further
assert that I do not currently have a current prescription for Valtrex from
another physician, nor am I taking any other treatment, oral medication, for
genital herpes (i.e. acyclovir).
[default to the ordering
information, no different than the other products]