Hay Fever Assessment | Pharma Aesthetics

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Hay Fever Treatment Medical Questionnaire

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Medical Questionnaire

Patient Notice: This Questionnaire forms the basis of your Hay Fever Treatment consultation today. We need you to be honest with your answers including any current medications you are on. This allows our doctors to prescribe medication that helps you and offer accurate advice. We expect you to read the medical information before selecting your treatment.

Your Symptoms

Are you experiencing itchy, watery eyes that have become bothersome recently?*

Yes

No

Please provide more information below.*

Do you frequently sneeze or have a runny or blocked nose without having a cold?*

Yes

No

Please provide more information below.*

Have you noticed any itchy throat, mouth, nose, or ears that cannot be explained by a cold or flu?*

Yes

No

Please provide more information below.*

Is your sense of smell diminished or altered in any way during these symptoms?*

Yes

No

Please provide more information below.*

Do you experience tiredness or fatigue that seems to coincide with your nasal or eye symptoms?*

Yes

No

Please provide more information below.*

Health

Are you currently taking any medication for hay fever or any other allergies?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you have any known allergies to antihistamines or corticosteroids, which are commonly used in hay fever treatments?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Are you pregnant, planning to become pregnant, or breastfeeding?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Do you suffer from any other conditions, such as asthma or eczema, that might be exacerbated by hay fever?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Have you previously tried any hay fever treatments that were ineffective or caused adverse reactions?*

Yes

No

Please provide more information (we ask this question so our doctors can make sure any treatment they prescribe is safe for you):*

Acknowledgements

Please Confirm

I understand if I start to experience any symptoms that seem out of the ordinary, I must see a GP.

These questions aim to gather comprehensive information to safely and effectively prescribe the correct treatment for hay fever, considering both the patient's symptoms and their overall health background.

Consent

We strongly advise that you inform your GP of any treatment you receive, Would you like us to inform them on your behalf?*

Yes

No

Your GP Address Details

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your Details

Name*

First Last

Phone*

Date of Birth*

Day

Month

Year

Your Home Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Please Confirm

Confirmation*

I Confirm

• I confirm I am over 18 years old
• The medicine is ordered for myself
• I will read the patient information leaflet supplied with the medicine and specifically the side effects and dosages
• I take responsibility to inform my own regular doctor of this online consultation or any changes in my circumstances.
• I agree to the Pharma Aesthetics Terms and Conditions.

If treatment is not suitable, you will be refunded and signposted to another point of care. The decision about treatment is for both the patient and the prescriber to consider, however, the final decision will always lie with the prescriber.

Phone

This field is for validation purposes and should be left unchanged.

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16 Broadway, Rainham, Essex, RM13 9YW
01708 608860
info@pharma-aesthetics.co.uk

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