Pharmacy First Infected Insect Bite Questionnaire NHS Pharmacy First - Infected Insect Bite Pre-Consultation QuestionnaireNHS Pharmacy First Service. This pre-consultation questionnaire is for patients aged 1 year and over seeking assessment for a suspected infected insect bite. Please note: A pharmacist review is required, and clinical assessment does not guarantee treatment or prescription of antibiotics.⚠️ Urgent Red Flag WarningIf you or the patient are experiencing any of the following, do NOT complete this form. Call 999 or go to the nearest Accident & Emergency (A&E) immediately:Difficulty breathing, chest tightness, or anaphylaxisSwelling of the face, eyes, lips, tongue, or mouthSevere systemic illness or signs of sepsis (confusion, slurred speech, extreme shivering, severe muscle pain, pale/blotchy skin)Rapidly spreading redness (expanding very quickly over a few hours)Do you have any of these urgent symptoms? Difficulty breathing / Anaphylaxis Swelling of face, eyes, mouth, or throat Signs of sepsis or severe systemic illness Rapidly spreading redness around the bite None of the abovePatient InformationPlease enter details for the patient requiring assessment.First NameLast NameDate of Birth (Age must be 1+)Is the patient under 16 years old? Yes NoParent/Guardian NamePhone NumberEmail AddressAddressAddress 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)Bite & Symptom DetailsPlease provide information about the insect bite.Where on your body is the bite located?When did the bite occur? (Or when did you first notice it?)What symptoms are you experiencing around the bite? (Select all that apply) Redness Swelling Warmth / Heat Pain / Tenderness Itching Pus or cloudy dischargeIs the redness spreading or getting larger over time? Yes NoDo you have a fever, high temperature, or feel generally unwell? Yes NoAre you experiencing any mild allergy symptoms (e.g. localized hives, mild itching elsewhere)? Yes NoUpload a photo of the bite (Optional but highly recommended)Upload Photo Medical History & SafetyImportant questions to ensure any treatment is safe for you.Is the patient pregnant or breastfeeding? Yes No Not ApplicableDo you have a weakened immune system (immunosuppressed)? Yes NoDo you have diabetes? Yes NoAre you currently taking any regular medicines?Do you have any known allergies?Have you tried any treatments for this bite already?Appointment & ConsentFinalize your pre-consultation request.When are you available for a consultation?- Select Availability -As soon as possible / TodayTomorrow morningTomorrow afternoonOther (Please specify in notes) I consent to the pharmacy team processing my clinical data for this consultation. I understand that a pharmacist review is required, that completing this form does not guarantee treatment or a prescription, and that I may be referred to another healthcare provider if appropriate.Submit Form
