Section B: Medical Express Medical Questions;

Allergy Clinic

Section B: Medical Express Medical Questions;

Your Health

Everyone having the allergy skin prick test or any other allergy test please fill this questionnaire. This is to get an overall view of your health and try and assist.

Patient name: ______Date: ______

To be filled by patient.

GENERAL MEDICAL QUESTIONS:

1. General Health.

a) Do you have or had in the past five years any of the following medical conditions: tick only if you had (or have). Leave it blank if none.

Asthma, eczema, rhinitis, conjunctivitis, dyspepsia, migraine,

epilepsy, severe behaviour problems, Jackle and Hyde personality,

joint pain, irritable bowel blotting, passing wind, foul smelling stools,

foul breathe, allergic disorder, anaphylaxis, tuberculosis , pneumonia ,

pleurisy , bronchitis , rheumatic fever , heart attack (MI) , angina

heart problems such as atrial fibrillation  , palpitation , raised blood pressure,

gastric or duodenal ulcer , recurrent indigestion , gallstone, jaundice,

colitis , piles , varicose veins ,

kidney or urinary trouble including kidney stones ,blood in urine , hernia ,

diabetes , gout , thyroid problem , arthritis / rheumatism , back trouble ,

gynaecological problem , prostate problems ,

poliomyelitis or other neurological disorder , anxiety or depression ,

psychiatric or mental health treatment , sleep disorder , snoring ,

ear, nose or throat disorder , eye disorder, skin disorder , malaria ,

hepatitis, anaemia , operations , serious accidents , serious head injury

If none, tick here for confirmation

If you tick “yes” to any of the questions, please give details: ______

2. Do you have ADHD or think you may have ADHD? No  Yes 

(ADHD may be triggered by food allergies)

3. Do you ever have (or had) Autism or Asperger’s syndrome? No  Yes 

(Some people consider Autism is trigged by food allergies)

4. Do you have any thought that you may autistic a tendency for Asperger’s syndrome?

No  Yes 

5. Do you wish to have detailed assessment for learning difficulties, giftedness, autism or Asperger’s? No  Yes . If yes, please discuss with the nurse.

If you have ticked yes to any of the questions, please give details separately and bring any report or assessments you have had before.

5 . Allergy.

Do you have any allergy or allergy related medical condition? No  Yes 

(Note: We have a clinic where we do investigation and treatment for allergic condition. If you wish to see a doctor with special interest in allergies, please tick here .)

If you wish to have Skin Prick Test for allergy detection, please tick here . You pay £59 instead of £200 to have this done by our allergy nurse specialist.

If you like to have RAST test (blood test) for allergies ask the nurses at the clinic)

Signature ______Date ______

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