Pharmacy First Shingles Questionnaire NHS Pharmacy First - Shingles Pre-Consultation QuestionnaireStep 1Step 2Step 3Step 4Step 5Step 6NHS Pharmacy First Service Shingles Pre-Consultation Questionnaire (Adults 18+)Please complete this form prior to your consultation. Note: A clinical assessment by the pharmacist is required, and the supply of antiviral treatment is not guaranteed.PreviousNextCRITICAL SAFETY SCREENING: If you experience any of the symptoms below, do NOT use this form. Seek immediate emergency medical care (Call 999 or go to A&E).Do you have any of the following urgent symptoms? (Select all that apply) Rash near/in the eye, nose, or ear Changes to your vision or hearing Severe headache or neck stiffness Confusion or drowsiness Weakness in your arms or legs Widespread rash covering multiple areas of the body Feeling extremely unwell or high fever with chills None of the abovePreviousNextFirst NameLast NameDate of Birth (Must be 18+)Contact Phone NumberEmail AddressFull AddressAddress Line 1Address Line 2Town/CityStatePostcodeCountrySelect 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)PreviousNextWhere is the rash located on your body?Is the rash strictly on one side of your body (left or right)? Yes NoAre you experiencing any of the following sensations in the rash area? Pain Tingling Itching Burning NumbnessHas the rash developed into fluid-filled blisters? Yes No, it is just red/bumpyWhen did the rash first appear?Did the rash start within the last 72 hours? Yes NoAre new spots/lesions still appearing? Yes NoDo you currently have a fever? Yes NoHave you ever had Shingles before? Yes No UnsureHave you had Chickenpox in the past? Yes No UnsureUpload a clear photo of the rash (Optional but highly recommended)Choose Image PreviousNextAre you currently pregnant or breastfeeding? Yes No Not ApplicableAre you currently immunosuppressed (e.g., due to chemotherapy, HIV, high-dose steroids, or other immunosuppressive medication)? Yes NoWhat regular medicines do you take?Do you have any known medication allergies?Have you tried any treatments for this rash already?PreviousNextYour Availability for Consultation (Phone or In-Person)Important Disclaimers:A clinical assessment by the pharmacist is mandatory before any treatment can be supplied.Antiviral medication supply is not guaranteed and is subject to clinical eligibility under NHS Pharmacy First guidelines.Your data will be processed securely in accordance with GDPR and NHS patient confidentiality standards. I consent to the pharmacy processing my medical information for this pre-consultation, and understand that a pharmacist assessment is required and antiviral supply is not guaranteed. Previous Submit Form
