Help us prepare for your appointment by completing this form in advance.
Welcome. This form does two things at once: it's the start of your care with us, and for Direct-tier patients it's also your full consultation.
Take your time. Allow 15-20 minutes. Everything you tell us is held in confidence under UK GDPR. Honest answers help us prescribe safely and recommend the right tier.
If you're unsure about a question, do your best — your reviewing doctor or nurse will follow up if anything needs clarifying.
You can switch tiers later. We may also recommend a different tier based on your safety screening answers.
The AUDIT is a WHO-validated screener used worldwide. Your honest answers help us recommend the right tier.
A drink = one pint of normal-strength beer, a small glass of wine, or a single measure of spirits.
If you're not sure, give your best estimate. A pint of beer = ~2 units; a small glass of wine = ~1.5; a large glass = ~3.
Includes tramadol, codeine, morphine, oxycodone, fentanyl patches, buprenorphine, methadone. This is an absolute contraindication for naltrexone — please answer carefully.
Naltrexone and nalmefene are not licensed for use in pregnancy or breastfeeding.
If you've ever had a withdrawal seizure, we'll need to talk before starting TSM — naltrexone doesn't address physical dependence.
This is a standard safety question. If your answer is anything other than 'Not at all', a clinician will review your case carefully and may recommend additional support before starting TSM.
Option 3 is only suitable for low-risk patients — your reviewing doctor will decide if that fits your case.
PDF or image. Helps us avoid charging you £49 for a new test if your existing one is recent enough.
Anything you would like your doctor to know before your appointment.
Your information is sent securely to your doctor at LoveMyLife. We will not share your details with third parties. By submitting this form, you consent to LoveMyLife contacting you regarding your appointment.