Altitude Sickness

Are you pregnant or breastfeeding?

Please answer all the questions accurately to ensure our clinicians can provide you with the best medication for your condition.

Yes

No

Is the patient aged 18 years or over? (If not, give details in the next question)

Yes

No

Are you allergic to sulphonamides?

Yes

No

Do you have glaucoma?

Yes

No

Do you have renal impairment, kidney stones or a history of kidney stones?

Yes

No

Do you have hepatic impairment or cirrhosis?

Yes

No

Do you have suprarenal gland failure (Addison disease)?

Yes

No

Do you have a history of Stevens-Johnson syndrome?

Yes

No

Do you have hyperchloremic acidosis?

Yes

No

Do you have low sodium (less than 133mmol/L)?

Yes

No

Do you have low potassium levels (less than 3.5mmol/L)?

Yes

No

Are you taking any of the following drugs:
- Lithium
- Phenytoin, phenobarbital, primidone
- Sodium valproate
- Carbamazepine
- Ciclosporin
- Methotrexate
- Methenamine
- Sodium bicarbonate
- High dose aspirin (>75mg daily)
- Oral anti-coagulants
- Other carbonic anhydrase inhibitors
- Cardiac glycosides
- Hypertensives

Yes

No

Please give details of where you will be travelling. (Try and include as much detail of specific dates of travel and also cities that will be visited)

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Altitude Sickness

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