Pharmacy First Impetigo Questionnaire NHS Pharmacy First - Impetigo Pre-Consultation QuestionnaireStep 1Step 2Step 3Step 4Step 5Step 6Pharmacy First Clinical Service Impetigo Pre-Consultation Assessment (Ages 1+)PreviousNext⚠️ Urgent Safety Warning (Red Flags)If the patient has any of the following symptoms, they may require immediate emergency care. Do not use this form. Call 999 or go to A&E immediately:Signs of sepsis (confusion, rapid breathing, severe shivering, pale/blotchy skin)Lesion is very close to or affecting the eyes/eyelids (risk of orbital cellulitis)Bullous impetigo (large fluid-filled blisters) in a neonate/infant under 1 yearPatient is systemically very unwell (e.g., lethargic, unresponsive, high fever unresponsive to medication)Does the patient exhibit any of the urgent red flags listed above? Yes (Seek immediate emergency medical help) NoIs the patient aged 1 year or older? Yes No (Impetigo Pharmacy First service is only for ages 1+)PreviousNextFirst NameLast NamePatient Date of BirthContact Phone NumberContact Email AddressPatient AddressAddress Line 1Address Line 2CityStatePostcodeCountrySelect CountryAfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicDemocratic Republic of the Congo (Kinshasa)DenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRepublic of the Congo (Brazzaville)RomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (Dutch part)Saint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom (UK)United States (US)United States (US) Minor Outlying IslandsUnited States (US) Virgin IslandsUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweNHS Number (Optional)Parent/Guardian Name (Required if patient is under 16)PreviousNextWhere are the sores/lesions located?How long have the lesions been present?- Select Duration -Less than 24 hours1 to 3 days4 to 7 daysMore than a weekApproximate number of lesions/sores:Do the sores have any of the following characteristics? (Select all that apply) Golden/honey-coloured crusts Fluid-filled blisters Red, itchy sores that burst None of the aboveAre the lesions spreading rapidly? Yes, spreading quickly Yes, but slowly No, staying the sameDoes the patient have a fever or feel generally unwell? Yes NoHas the patient had impetigo before in the last 3 months? Yes NoIs there eczema, a cut, or broken skin at the site of the sores? Yes NoUpload a photo of the affected area (Highly Recommended)Choose File PreviousNextIs the patient pregnant or breastfeeding? Yes No Not ApplicableIs the patient immunosuppressed (e.g., undergoing chemotherapy, taking oral steroids, HIV positive)? Yes NoDoes the patient have diabetes? Yes NoCurrent MedicationsAllergiesPrevious Treatments Tried for this EpisodePreviousNextWhen are you available for a consultation (phone or in-person)? Morning (9am - 12pm) Afternoon (12pm - 5pm) Evening (5pm - 8pm)Important Information: This form is a pre-consultation tool. A pharmacist review is strictly required. Filling out this form does not guarantee a diagnosis or that treatment (such as antibiotics) will be prescribed. I consent to the pharmacy processing my clinical data for this NHS Pharmacy First consultation, and I understand that a pharmacist clinical review is required before any diagnosis or treatment can be offered. Previous Submit Form
