Pharmacy First Sinusitis Questionnaire NHS Pharmacy First - Acute Sinusitis Pre-Consultation QuestionnaireStep 1Step 2Step 3Step 4Step 5Step 6Pharmacy First Service Acute Sinusitis Pre-Consultation Questionnaire (Ages 12+)Important Notice: This questionnaire helps assess your suitability for the Pharmacy First Sinusitis service. Fill out this form honestly. Please note: Completing this form does not guarantee a diagnosis or a prescription for antibiotics.PreviousNextDo you have any of the following urgent symptoms? (Select all that apply) Swelling, redness, or pain around one or both eyes Double vision, reduced vision, or changes in sight Severe frontal headache (severe forehead pain) Stiff neck Neurological symptoms (e.g., weakness, numbness, difficulty speaking) Confusion, drowsiness, or altered mental state Rapidly deteriorating or worsening condition None of the abovePreviousNextFirst NameLast NameDate of BirthNHS Number (Optional)Contact Phone NumberEmail AddressPreviousNextHave your sinusitis symptoms lasted for 10 days or more? Yes, 10 days or more No, less than 10 daysWhich of the following symptoms are you currently experiencing? (Select all that apply) Nasal blockage / congestion Nasal discharge (runny nose or mucus dripping down the back of throat) Facial pain, pressure, or fullness (especially around cheeks, eyes, or forehead) Fever (high temperature) Tooth pain (especially upper jaw/teeth) Unilateral symptoms (symptoms predominantly on one side of the face) Worsening symptoms (symptoms got better, then suddenly worsened again)PreviousNextAre you currently pregnant or breastfeeding? Yes No Not ApplicableAre you immunosuppressed or taking any immune-suppressing medications? Yes NoDo you suffer from recurrent sinusitis? Yes NoCurrent MedicationsAllergiesWhat treatments have you tried so far?PreviousNextPreferred Consultation Time- Select a time window -Morning (9am - 12pm)Afternoon (12pm - 4pm)Evening (4pm - 7pm)AddressAddress Line 1Address Line 2CityPostcode I confirm the information provided is accurate. I do consent to assessment and GP notification where appropriate. I understand this questionnaire must be reviewed before my appointment request can be accepted. Previous Submit Form
