Mouth Ulcer Relief – Quick Online Assessment.Please complete this confidential form. Our clinician will review and respond shortly. Name * First Name Last Name Date Of Birth * MM DD YYYY Gender * Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### This section helps us understand your current symptoms and whether treatment is suitable. ⚠️ If you answer 'Yes' to any of the questions below, this may suggest a more serious cause may be possible. We recommend you speak to your GP or a dentist for further investigation. * How many ulcers do you currently have? 1 2-5 5+ Where are they located? * Inside lip Inside cheek Tongue Roof of mouth Gums Other How long have they been present? * Less than 1 week 1–2 weeks More than 2 weeks Are they painful or interfering with eating/drinking? * Yes No Do you get ulcers regularly? * Yes No Please describe your symptoms in your own words * These questions help rule out more serious causes of mouth ulcers. * Has the ulcer lasted longer than 3 weeks? Yes No Is there any associated bleeding or swelling in your mouth? * Yes No Do you have difficulty swallowing, chewing, or speaking? * Yes No Have you had unexplained weight loss or persistent tiredness? * Yes No Have you noticed any lumps in your neck or mouth? * Yes No Are you a smoker or heavy alcohol user? * Yes No Have you had recent dental surgery or trauma to the area? * Yes No Have you used any treatments for mouth ulcers before? * Yes No If yes, please list them (e.g., Bonjela, Corsodyl, hydrocortisone buccal tablets) Do you have any history of: * Iron deficiency Vitamin B12/folate deficiency Crohn’s disease Coeliac disease Behçet’s disease None Do you take any regular medications? * Yes No Please list your regular medications Do you have any known allergies to medications? * Yes No If yes, please specify Have you been feeling generally unwell? * Yes No Have you recently had a viral illness or cold? * Yes No Are you currently under the care of a GP or dentist for this issue? * Yes No Would you like us to notify your GP of this consultation? * Yes No Consent & Declaration * I confirm the information I’ve provided is true and complete. I understand this service is for simple, short-term mouth ulcers only I will seek medical advice if symptoms persist or worsen. I consent to my information being used for clinical assessment and prescribing. Thank you! Your consultation has been submitted. A clinician will review your answers and get back to you shortly.