LDN Assessment - RemiVida | Remedies for Life

LDN Assessment (#8)

Your Condition
Your Symptoms
Current Treatments
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What is the main condition for which you are requesting Low Dose Naltrexone?

Fibromyalgia

ME / Chronic Fatigue Syndrome

Long COVID / post-COVID condition

Mast Cell Activation Syndrome – MCAS

Crohn’s disease

Ulcerative colitis / inflammatory bowel disease

Hashimoto’s thyroiditis

Chronic pain

Neuropathic pain

Multiple sclerosis

Another autoimmune or inflammatory condition

Other

Fibromyalgia

Please tell us more about your condition

Have you received a formal diagnosis of fibromyalgia?

Yes

Approximately when were you diagnosed?

Which symptoms currently affect you most?

Widespread pain

Fatigue

Poor sleep

Cognitive symptoms

Headaches

IBS-type symptoms

Other

Which treatments have you previously tried?

Are you currently under a pain clinic or rheumatology service?

Yes

ME / CFS

Please answer the following questions if you suffer from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome

Have you received a formal diagnosis of ME/CFS?

Yes

Do you experience post-exertional malaise?

Yes

Unsure

How would you currently describe your functional ability?

Midly affected

Moderately affected

Severely affected

Very severely affected

Are you currently under an ME/CFS or specialist service?

Yes

Which symptoms would you most like treatment to improve?

Long COVID

When did you first have COVID-19?

Was the infection confirmed by a test?

Yes

Unsure

Approximately how long have your ongoing symptoms been present? Please advise us how many years and/or months

Years and Months

Have you been diagnosed with Long COVID/post-COVID syndrome?

Yes

Under investigation

Are you attending an NHS Long COVID clinic?

Yes

Which symptoms currently affect you?

Fatigue

Post-exertional malaise

Brain fog

Muscle/joint pain

Sleep disturbance

Breathlessness

Palpitations

POTS-type symptoms

Other

MCAS

Mast Cell Activation Syndrome is associated with inappropriate activation of mast cells and release of chemical mediators.

Have you been formally diagnosed with MCAS?

Yes

Under investigation

Who made the diagnosis?

Do you experience any of the following symptoms?

Flushing

Hives

Itching

Gastrointestinal symptoms

Wheezing

Palpitations

Dizziness

Episodes of swelling

Anaphylaxis

Other

Have you ever experienced anaphylaxis?

Yes

Do you carry an adrenaline auto-injector?

Yes

What treatments are you currently using for MCAS?

Crohn’s / IBD

There has been research into the potential use of Low Dose Naltrexone in inflammatory bowel disease, particularly Crohn’s disease. The evidence remains limited, however.

Important:

LDN should not be used as a substitute for established IBD medication or specialist gastroenterology care simply because someone has read about it online.

Which condition have you been diagnosed with?

Crohn’s disease

Ulcerative colitis

Other IBD

When were you diagnosed?

Are you currently under the care of a gastroenterologist?

Yes

Are you currently experiencing an IBD flare?

Yes

Unsure

Have you recently experienced significant bleeding, severe abdominal pain, fever or rapid deterioration?

Yes

What IBD medicines are you currently using?

Hashimoto’s

Hashimoto’s thyroiditis is an autoimmune condition affecting the thyroid.

LDN is sometimes discussed as an adjunctive off-label treatment in autoimmune thyroid disease, but evidence for clinical benefit is limited.

It does not replace thyroid hormone replacement such as levothyroxine where that treatment is required.

Have you been formally diagnosed with Hashimoto’s thyroiditis?

Yes

Are you currently taking thyroid hormone replacement?

Yes

Which hormone replacement medicine and dosage?

When did you last have thyroid blood tests?

Were the results considered stable?

Yes

Don’t know

Are you currently under your GP or an endocrinologist for thyroid treatment?

Yes

Chronic pain / neuropathic pain

Some description about this section

What is the cause of your pain, if known?

How long have you had the pain?

Average pain score during the last week

What pain medicines are you currently taking?

Do you attend a pain clinic?

Yes

Have you received a formal diagnosis of this condition from a healthcare professional?

Yes

Currently under investigation

Who diagnosed you and approximately when?

Your Symptoms

A few questions to help us understand your issues.

How long have you experienced symptoms?

Less than 3 months

3–6 months

6–12 months

1–2 years

More than 2 years

More than 5 years

Please describe the main symptoms you would like to improve

On a scale of 0–10, how much do your symptoms currently affect your everyday life?

Which symptoms do you currently experience?

Widespread pain

Joint pain

Muscle pain

Nerve pain / burning / tingling

Headaches

Fatigue

Post-exertional malaise

Poor sleep

Brain fog / concentration problems

Memory difficulties

Gastrointestinal symptoms

Diarrhoea

Constipation

Abdominal pain

Flushing

Itching / hives

Palpitations

Dizziness

Temperature sensitivity

Low mood

Anxiety

Other

Have your symptoms recently become significantly worse?

Yes

If yes, please explain

Treatments

Please provide us with details of current and previous treatments by answering the questions below

What treatments have you already tried for this condition?

Are you currently under the care of a GP, consultant or specialist for this condition?

Yes

Please provide details

Are you currently taking prescription medication for this condition?

Yes

Please list medicines & doses

Have you previously taken Low Dose Naltrexone?

Yes

Which strength did you take? (mg)

How long did you take it for?

Did you feel it helped?

Yes

Unsure

Did you experience any side effects?

Why did you stop taking it?

Important: Naltrexone and opioid medication

Naltrexone blocks opioid receptors and may be unsuitable or potentially dangerous when taken with opioid medicines.

It is essential that you tell us about all opioid medication, including medication taken only occasionally.

Are you currently taking any opioid medication?

Yes

Unsure

Have you taken any opioid-containing painkiller within the last 30 days?

Yes

Unsure

Which medicine?

Which dose?

When did you last take it?

Do you regularly use codeine-containing medicines available from a pharmacy?

Yes

Do you use any opioid-containing cough medicines?

Yes

Are you currently receiving treatment for opioid dependence?

Yes

Have you used heroin or other non-prescribed opioids recently?

Yes

Please provide details

Do you expect to require opioid pain relief in the near future, for example because of planned surgery or a medical procedure?

Yes

Please give details

Current medication

Please list ALL prescription medicines you currently take

Please list any over-the-counter medicines you regularly use

Please list any supplements or herbal products you regularly use

Have you started, stopped or changed any medication during the last four weeks?

Yes

Please explain

Allergies and previous reactions

Are you allergic to naltrexone?

Yes

Never taken it

Do you have any medication allergies?

Yes

Please provide details

Have you previously had a serious reaction to a medicine?

Yes

Please explain

Liver health

Have you ever been diagnosed with liver disease?

Yes

select or explain

Fatty liver disease

Alcohol-related liver disease

Hepatitis

Cirrhosis

Raised liver enzymes

Other

Have you ever been told that your liver blood tests were abnormal?

Yes

Don’t know

Please provide details

Have you had liver-function blood tests during the last 12 months?

Yes

Don’t know

Approximately when?

Were the results normal?

Yes

Don’t know

Please upload your blood test results if available

Click to select file or drop file here

Have you ever had jaundice — yellowing of the skin or eyes?

Yes

Kidney Health

Do you have kidney disease or reduced kidney function?

Yes

Don’t know

Please provide details

Are you receiving dialysis?

Yes

Other medical conditions

Have you ever been diagnosed with any of the following?

Heart disease

High blood pressure

Kidney disease

Liver disease

Epilepsy or seizures

Diabetes

Thyroid disease

Autoimmune disease

Crohn’s disease

Ulcerative colitis

Multiple sclerosis

Fibromyalgia

ME/CFS

Long COVID

MCAS

POTS

Cancer

Serious infection

Mental-health condition

Eating disorder

None of the above

Other

Mental Health

Some description about this section

Have you ever been diagnosed with a mental-health condition?

Yes

Please indicate the nature of the mental health issue

Depression

Anxiety disorder

Bipolar disorder

Psychosis / schizophrenia

PTSD

Other

Are you currently receiving treatment for a mental-health condition?

Yes

Have you had thoughts of harming yourself or ending your life recently?

Yes

You must immediately contact your G.P., mental health professional or a suitable organisation to provide you with help and advice. Do not contine this consultation any further

Pregnancy and breastfeeding

Are you currently pregnant?

Yes

Unsure

Not applicable

Are you currently breastfeeding?

Yes

Not applicable

Are you trying to become pregnant?

Yes

Not applicable

Is there a possibility you may currently be pregnant?

Yes

Not applicable

Surgery and pain treatment

Are you due to have surgery, dental surgery or another medical procedure during the next 3 months?

Yes

Please provide details

Are you currently attending a pain clinic?

Yes

Do you have a condition that regularly requires strong opioid pain relief?

Yes

Why are you requesting LDN?

Where did you first hear about Low Dose Naltrexone?

Consultant

Other healthcare professional

Friend or family

LDN Research Trust

Online search

Facebook / social media

Patient group

RemiVida

Other

What are you hoping LDN will help you achieve?

What would you personally regard as a successful response to treatment?

Understanding of treatment

I understand that Low Dose Naltrexone is being considered for an off-label use and may not be licensed specifically for my condition.

I understand

I understand that scientific evidence for LDN varies considerably depending on the condition being treated and that improvement cannot be guaranteed

I understand

I understand that I must take the medication only according to the instructions issued by my prescriber and pharmacy

I understand

I understand that I should not increase or decrease my dose independently simply because different doses are contained within my Starter Pack

I understand

I understand that naltrexone blocks opioid receptors and that opioid medication may interact significantly with naltrexone

I understand

I confirm that I have disclosed any opioid medicines or opioid drugs I currently use or have recently used

I understand

I understand that I should seek medical advice before surgery or emergency pain treatment and tell healthcare professionals that I take naltrexone

I understand

I understand that I should not stop existing prescription medicines without discussing this with the healthcare professional responsible for my treatment

I understand

I understand that purchasing this service does not guarantee that a prescription will be issued

I understand

Contact Details

You can now create your account, so you will be able to purchase your medication, once approved by clinicians.

First Name

Last Name

Password

Retype Password

Phone/Mobile

Address

Address Line 1

Address Line 2

City

County

Post Code

Gender

Male

Female

Other

Date of Birth

Name of your GP practice

NHS Number (if known)

Please upload a picture of your Photo ID (Driving Licence or Passport)

Choose File

Accuracy declaration

Please confirm

I confirm that:

the information I have provided is accurate and complete;
I have disclosed all medication I currently take;
I have disclosed any recent opioid use;
I have disclosed relevant medical conditions;
I will tell the clinical team if my health or medication changes;
I will follow the instructions provided by my prescriber and pharmacy;
I understand that withholding relevant medical information could make treatment unsafe.

Accuracy Confirmation

I confirm the accuracy of all the statements above