Date
Patient Name	Select One Mr Mrs Miss Ms
Parent/Guardian Name
Occupation
Ethnicity
Address
?
Date of Birth
Phone (Work)
Phone (Home)
Email
N.H.I No: (if known)

Do you have Medical Insurance? ? Yes No

Company

GENERAL PRACTITIONER'S DETAILS

Name
Address
?

List your main symptoms or complaints (with duration):

A:
B:
C:
D:

List ALL medicines you take (including herbal, vitamins, etc.):

?

None

Answer ALL the following questions by ticking either YES or NO. Any comments regarding these questions can be entered below.

Have you had Allergy Tests before?	Yes?? No
Have you had Immunotherapy (desensitisation) before?	Yes?? No
Have you ever had a severe reaction to a Bee or Wasp sting?	Yes?? No

How did this reaction manifest itself?

?

Have you ever had an Anaphylactic Reaction? (Sudden severe collapse/shock after food, drugs or any cause.)

Yes?? No

What was the cause?

?

Is your condition seasonal?

Yes?? No

If so, which season is worse?

?

How often do you have your attacks?

?

How long do they last?

?

Do you suffer from Asthma?	Yes?? No
Do you suffer from Eczema?	Yes?? No
Do you suffer from Hives (Urticaria)?	Yes?? No
Do you suffer from Hay Fever?	Yes?? No
Do you suffer from Sinus Troubles?	Yes?? No
Do you suffer from Frequent Colds?	Yes?? No
Do you suffer from Persistent Cough?	Yes?? No
Do you suffer from Diarrhoea?	Yes?? No
Do you suffer from Abdominal Cramps?	Yes?? No

Comments

CONTACT ALLERGY

Have you ever had a skin reaction to Jewellery?	Yes?? No
Have you ever had a skin reaction to Skin Care Products / Cosmetics?	Yes?? No
Have you ever had a Patch Test?	Yes?? No

CHILDHOOD ALLERGIC HISTORY

Did you have Asthma?	Yes?? No
Did you have Eczema?	Yes?? No
Did you have runny nose (Rhinitis) / Hay Fever?	Yes?? No
Did you have Vomiting, Diarrhoea or Colic?	Yes?? No

FAMILY HISTORY Have any of your first degree relatives (parents or siblings) had:

Asthma?

Yes?? No

Relationship

Eczema?

Yes?? No

Relationship

Rhinitis (Hay Fever)?

Yes?? No

Relationship

FOOD HISTORY

Do you suspect any foods as causing symptoms?

Yes?? No

Which one(s)

Are you omitting any food(s) at present?

Yes?? No

Which one(s)

ENVIRONMENTAL HISTORY

Do you have a Cat?	Yes?? No
Do you have a Dog?	Yes?? No
Are your symptoms better on Holidays?	Yes?? No
Are you worse at Work?	Yes?? No
Do you have any Hobbies?	Yes?? No

DRUG HISTORY

Are you sensitive / allergic to any Drugs?

Yes?? No

Which one(s)

EXERCISE HISTORY

Are your symptoms brought on or worsened by Exercise?

Yes?? No

GENERAL MEDICAL HISTORY

Have you ever had an operation on your Sinuses?	Yes?? No
Do you have High Blood Pressure?	Yes?? No
Are you a Diabetic?	Yes?? No
Are you Pregnant?	Yes?? No
Do you Smoke?	Yes?? No

NEWSLETTERS & UPDATES

Would you like to receive newsletters and updates from us?

Yes?? No