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Medical Assessment - Jet Lag

Health

Are you allergic to lactose?

Circadin contains Lactose. Please consult with your GP.
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Do you have any of the following?

  • Kidney problems
  • Liver problems
  • Heart problems
  • Any Autoimmune condition (e.g. rheumatoid arthritis, Graves’ disease)
  • Galactose intolerance, LAPP lactase deficiency or glucose-galactose malabsorption
  • Alcohol dependency
  • Depression requiring treatment with medication
  • Schizophrenia or Bipolar Disorder
  • Epilepsy (or ever suffered a seizure)
We are unable to supply you with this treatment. Please see your GP.
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Are you pregnant or breastfeeding?

We are unable to prescribe you Circadin if you are pregnant or breastfeeding.
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Medication

Are you taking any of the following medications?

  • Benzodiazepines (e.g. diazepam, temazepam, lorazepam)
  • Zopiclone or Zolpidem (or any other sleeping tablets)
  • Fluvoxamine
  • Alcohol
  • Cimetidine
  • Oestrogen containing medication (e.g. HRT or combinec contraceptive pill)
  • Warfarin or any other blood thinning medication
  • carbamazepine
  • rifampicin
  • quinolones or fluoroquinolones (e.g. ciprofloxacin)
  • pipemidic acid
  • teriflunomide
  • leflunomide
  • axitinib
We are unable to supply you with treatment if you do not know how or when to use an inhaler. Please consult your GP or asthma clinic.
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Circadin, as a medication that helps you sleep, can enhance the effects of sleepiness or low blood pressure with a number of medications. Below is a list of medications whose side effects could be enhanced by circadin. Do you understand that if you are on these medications and have any symptoms of light headedness, muzziness or excessive sleepiness you should immediately stop your Circadin?

  • Alcohol
  • Alpha-blockers (e.g. Doxazocin, Alfuzosin, Tamsulosin, Prazocin)
  • Antidepressants, Tricyclic
  • Antihistamines
  • Antipsychotics
  • Myelosuppressive drugs
  • Baclofen
  • Beta-blockers
  • Calcium-channel Blockers
  • Clonidine
  • Diazoxide
  • Diuretics
  • Guanfacine
  • Hydralazine
  • Lofexidine
  • Methyldopa
  • Minoxidil
  • Mirtazapine
  • Moxonidine
  • Nitrates
  • Opioid Analgesics
  • Phenobarbital
  • Primidone
  • Ritonavir
  • Sodium Nitroprusside
  • Tizanidine
We are unable to supply you with this treatment. Please see your GP.
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Agreement

Do you understand that although many studies show Circadin (melatonin) helps with jet lag and is safe to use, it is not specifically licensed for this use in the UK? Nevertheless, it benefits many people who regularly cross time zones. Our prescribers have given this consideration, and will prescribe this for you if you acknowledge and understand this statement, and confirm you have visited and read this website.

We are unable to supply you with this treatment. Please see your GP.
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Do you understand that Circadin should be taken daily, 1-2 hours before your intended bedtime in your new time zone?

Please read the Circadin product information and change your answer.
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Do you understand that should not take Circadin with alcohol?

Both Circadin and Alcohol have sedative effects, and combining them can be dangerous. Taking Circadin following a small intake of alcohol (up to 2 units) is unlikely to be harmful, however there is always a risk, and this risk increases the more alcohol you drink. If you accept this risk, change your answer and continue.
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Do you understand that Circadin can cause drowsiness, so you should not drive or operate heavy machinery for at least 8 hours after taking Circadin?

We are unable to supply you with this treatment. Please see your GP.
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Do you agree to the following?

  • You will read the patient information leaflet supplied with your medication
  • You will contact us and inform your GP of your medication if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
  • The treatment is solely for your own use
  • You have answered all the above questions accurately and truthfully. You understand our prescribers take your answers in good faith and base their prescribing decisions accordingly, and that incorrect information can be hazardous to your health.
You must agree to this before continuing. If you need assistance contact customer support.
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