Gout Consultation e-form

Gout Consultation e-form
Patient Information
NHI*
Date of Birth*

DayMonthYear
Free type or use calendar date picker
Ethnicity*
Town*
Informed consent | Healthify
Patient Consent*

Patient/Caregiver understands and agrees to participate in this service and consents for the pharmacist to access relevant medical records and share relevant information with other healthcare providers. They agree that anonymised data may be used to improve this service.
Consultation Data
1. Reason for Gout Consultation*

Presented for pain reliefInitiated on urate-lowering medicineOnly using pain relief/no preventerNon-adherent with gout medicineRegular Allopurinol - NO URIC ACID TEST RECENTLYRegular Colchicine/NSAID - NO PREVENTEROther
2. Frequency of Gout Attacks:*

Every monthOnce per year2 or more times per yearInfrequent
3. Understanding of Gout *
Use + to enter 1-5 (1 = Poor, 5= Excellent)
4. Understanding of Uric Acid & Targets *
Use + to enter 1-5 (1 = Poor, 5= Excellent)
5. Is patient on urate-lowering therapy?*
6. Is allopurinol being titrated appropriately?*
7. 1st Point of Care of Test provided today*

NOYES- enter Uric Acid Result (mmol/L)
8. Reason for Uric Acid Point of Care Test

OpportunisticCant get to labNo lab form from DrNon adherant with gout medicinesMonitoring
9. Referred to GP? Why*

Uric Acid >0.36mmol/LMore than 2 gout attacks in a yearPoor AdherenceAdverse effectsNo urate lowering therapyIssues with allopurinol titrationOther
Additional Clinical Notes (Voluntary)
Free text field for your note taking
Pharmacist Declaration
Pharmacy Name (choose from list)*
Pharmacist Full Name*

First NameLast Name
Pharmacy Dispensary Email*
Pharmacist Declaration*

I agree that I have explained the consent process to the patient and I have conducted a comprehensive consultation utilising the MidCPG Gout Consultation Checklist
Signature*

Clear
Date of Consultation*

DayMonthYear
Free type or use calendar date picker
Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.
Patient Full Name (REMOVE via PETE 15/12/2025)*

First NameLast Name
Should be Empty:

Gout Consultation e-form

Patient Information

Consultation Data

Pharmacist Declaration

Pharmacist: Please check all fields are accurate before submitting. A report will be emailed to your dispensary email.