Date (dd/mm/yyyy )	(ex: 03/12/2015)
Patient Name	Select One Mr Mrs Miss Ms
Parent/Guardian Name
Occupation
Ethnicity
Address
Date of Birth (dd/mm/yyyy )	(ex: 03/12/1984)
Phone (Work)
Phone (Home)
Email
N.H.I No: (if known)

Do you have Medical Insurance?   Yes No

Company

Would you like your consult letters to be sent to your General Practice ?   Yes No

Name
Address

List your main symptoms or complaints (with duration):

A:
B:
C:
D:

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

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