Sleep consultation

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Name *

First

Last

Date of birth *

Email *

Phone *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Country

How long does it typically take you to fall asleep after going to bed? *

Less than 30 minutes
30-60 minutes
More than 60 minutes

How many hours of sleep do you usually get per night? *

Less than 4 hours
4-6 hours
6-8 hours
More than 8 hours

How often do you wake up during the night? *

Rarely
1-2 times per night
3 or more times per night

Do you wake up earlier than desired and are unable to fall back asleep? *

How refreshed do you feel upon waking? *

Very refreshed
Somewhat refreshed
Not refreshed at all

Do you take naps during the day? *

Never
Occasionally
Frequently

Do you sleep in a quiet, dark, and comfortable environment? *

How often do you consume caffeine or alcohol, especially in the evening? *

Never
Occasionally
Frequently

How often do you use electronic devices (phone, tablet, TV) within 1 hour of bedtime? *

Never
Occasionally
Frequently

Do you exercise regularly? *

Do you often feel stressed or anxious before bed? *

Have you experienced any significant emotional events or traumas recently? *

Do you have a history of depression, anxiety, or other mental health conditions? *

Do you snore loudly or has anyone noticed you stop breathing during sleep? *

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

Do you experience any of the following symptoms during the night? *

Restless legs
Night sweats
Teeth grinding
Sleepwalking
None of the above

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 frequently have nightmares or disturbing dreams? *

Do you feel sleepy or doze off during the day, even during activities such as working or driving? *

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 medications that may affect your sleep? *

Please list the medicines here *

Have you been diagnosed with any sleep disorders? *

Please provide more details *

Do you work night shifts or have an irregular work schedule? *

Do you have a regular bedtime routine? *

Please select your treatment *

Antihistamine based treatments such as Nytol and Sominex
Melatonin

Have you used Melatonin before? *

Did you experience any side effects when using Melatonin? *

Please tell us about the side effects you experienced with Melatonin. *

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 condition red flag *

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 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 Drug Red Flag *

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

Have you used antihistamines such as Nytol and Sominex fo insomnia before? *

Did you experience any side effects when using this treatment? *

Please tell us what the side effects you experienced when using this treatment? *

How often did you need to take it before? Select one answer *

1 – 2 times a week
3 – 4 times a week
Nightly

How long did you take the treatment? Select one answer *

Occasionally
1-2 months
Continuously

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 take any of the following medicines:

Medicines called MAOIs (Mono Amine Oxidase Inhibitors)
Anticholinergic medicines – Used for irritable bowel syndrome, asthma or weak bladder
Medicines used to reduce or prevent seizures (e.g. in epilepsy)
Strong pain killers (e.g. codeine, morphine or buprenorphine)
Medicines for depression (such as amitriptyline)
Medicines for treating mental illness (such as promazine, flupentixol or haloperidol)
Medicines to help you sleep or feel more relaxed (such as diazepam or zolpidem)
Medicines such as aspirin (for arthritis and pain in your joints)
Isocarboxazid
Phenelzine

Nytol medicines Red Flags *

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 any of the following apply:

Difficulty breathing, wheezing, tightness in the chest (asthma) or an infection in your lungs (bronchitis)
You have epilepsy or suffer from seizures
You suffer from myasthenia gravis
You have any serious heart problems
You have liver or kidney problems
You have a stomach blockage or difficulty passing water (urine)
You have increased pressure in the eye (narrow-angle glaucoma)

Nytol Medical Condition Red Flag *

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 understand that:

The maximum dose of nytol is 50mg daily at night taken 20 minutes before bed.
- This can be one 50mg tablet or up to two 25mg tablets.
Nytol should not be taken for longer than 14 days consecutively.
You should not drink alcohol whilst taking Nytol.
We are unable to supply this medicine to anyone aged under 18 years.

Nytol understanding *

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 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.

Sleep consultation

Do you agree and consent to the following?

Conditions

Treatments

Care and policies