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2nd Floor, Akerman Health Centre
60 Patmos Road, London, SW9 6AF
Tel. 020 3049 6500
Fax. 020 3049 6515
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Allergies / Hayfever Online Consultation

Please fill out the form below, and one of our doctors will contact you regarding the consultation:

Patient Information

Name: *
Date Of Birth: *
NHS Number (if known):
Address:
Postcode:
Contact Number: *
E-Mail Address: *

Consultation Information

1. Have you read information about your symptoms on Patient.info?

    It is advised that you read up about this condition and the related symptoms.

    Yes

    No

    2. Which of the following hay fever symptoms do you experience? Please tick all that apply.

      Runny or blocked nose
      Frequent sneezing
      Itchy, red eyes
      Wheezing or difficulty breathing

      3. Please specify any other symptoms you are experiencing

        4. Have you had recurrent nose bleeds, blood stained or green discharge, pain OR discharge from your nose?

          Yes

          No

          5. If you answered yes, please give more details:

            6. Have you ever used antihistamine tablets for your hayfever?

              Yes

              No

              7. Have you ever used steroid nasal spray for your hayfever?

                Yes

                No

                8. If you answered yes, which steroid nasal spray did you use?

                  Yes

                  No

                  9. If you answered yes, how long did you take it for?

                    10. If you answered yes, did you find the steroid nasal spray beneficial?

                      11. If you answered yes, please specify which ones:

                        12. If you answered yes, please specify any side-effects you have experienced from them:

                          13. Are you aware that you should do regular steam inhalation for your hayfever?

                            Yes

                            No

                            14. Are you aware that you should do regular nasal lavage (washing the insides of the nose with warm water) for control of your hayfever symptoms?

                              Yes

                              No

                              15. Are you aware that you need to use nasal sprays for at least 3-6 months for control of your symptoms?

                                Yes

                                No

                                16. Do all of the following apply to you?

                                • I will read the patient information leaflet supplied with my medication.
                                • The medication is for my own use. (Partners, spouses etc must log out, complete their own consultation and register separately)
                                The conditions must apply for you to be able to use this service.

                                Yes

                                No