Section 1: Personal details

Section 2. What type of pain are you experiencing?

Please select all that apply:

Muscle or joint painBack or neck painHeadache / migrainePeriod painDental painNerve pain (e.g., pins & needles)Other

How long have you been experiencing this pain?

Section 3. On a scale of 0-10, how would you rate your current pain?

0 = no pain, 10 = worst possible pain: ____/10

Section 4. Have you tried any pain relief yet?

4. Have you tried any pain relief yet?

Yes — over the counterYes — prescriptionNo

Section 5. Are you currently taking any of the following medications? (Please tick all that apply)

Other NSAIDs (e.g., ibuprofen, diclofenac)Anticoagulants / blood-thinners (eg warfarin, DOACs)Steroids (oral or injectable)Kidney medicineLiver medicineNone of the aboveOther medications

Section 6. Do you have any of the following medical conditions? (Please tick all that apply)

Ulcer or bleeding in stomach or intestinesSevere liver disease or cirrhosisSevere kidney disease or on dialysisHeart failure or recent heart attackAsthma that is poorly controlledAllergy to pain medicines or NSAIDsPregnant, trying to get pregnant, or breastfeedingNone of the aboveOther long-term medical condition

Section 7. Any known allergies?

YesNo

Section 8. Consent & Declaration

I confirm the answers I have given are complete and correct to the best of my knowledge.

I understand that the pharmacist will review my responses and determine whether Naproxen or other pain relief is appropriate for me.

I understand that all medicines have risks and I will follow the pharmacist’s guidance for safe use.