Pharmacy First Earache Questionnaire Pharmacy First QuestionnairePharmacy First Questionnaire Please complete this form before booking so the pharmacy team can review whether an appointment is suitable. First NameDate Of BirthNHS NumberEmail Parent / Guardian NameAddress AddressAddress Line 1Address Line 2CityZip CodeEar Symptoms1. How long have you had a problem with your ear(s)? Less than 3 days More than 3 days2. Which ear(s) are affected? Right ear Left ear Both ears3. Do you have any of the following symptoms? Pain in the ear(s) Fluid coming from the ear(s) Hearing loss or a change in hearing Fever Cough Holding, tugging or rubbing the ear Runny nose Reduced food or fluid intake Feeling restless or cryingUrgent Symptoms4. Do you have any of the following symptoms? Neck stiffness or sensitivity to light Mottled or blotchy skin Swelling or pain behind the affected ear(s) Severe headache Feeling irritable or confused Weakness in the arms or legs Facial drooping Pain behind or around the eyesMedical History5. Do you think your symptoms are improving? Yes No - they are the same No - they are getting worse6. How many ear infections have you had in the past 6 months?- Select -01234 or more7. Have you tried anything to manage your symptoms?8. Please list any medical conditions you have below9. Were you born prematurely? Yes No Not SureImmune System, Pregnancy & Allergies10. Do you have a condition or use any medications that cause a weakened immune system? * Yes No 11. If yes, what is the cause of your weakened immune system?12. Is there a possibility you might be pregnant? Yes No Not Applicable13. Do you have any allergies? Yes No 14. If yes, please list any allergies and what reaction you get with themAppointment Availability15. Are you able to come into the Pharmacy for an appointment? Yes No 16. If yes, please tell us when you are available during our opening hours17. If no, please tell us the best times to contact youConsent15. Are you able to come into the Pharmacy for an appointment? 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.Submit Questionnaire
