Pharmacy First Form – Gees Chemist

Pharmacy First Questionnaire

First Name

Date Of Birth

NHS Number

Parent / Guardian Name

Address

Address Line 1

Address Line 2

City

Zip Code

Ear Symptoms

1. How long have you had a problem with your ear(s)?

Less than 3 days

More than 3 days

2. Which ear(s) are affected?

Right ear

Left ear

Both ears

Urgent Symptoms

4. 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 eyes

Medical History

5. Do you think your symptoms are improving?

Yes

No - they are the same

No - they are getting worse

6. How many ear infections have you had in the past 6 months?

7. Have you tried anything to manage your symptoms?

8. Please list any medical conditions you have below

9. Were you born prematurely?

Yes

Not Sure

Immune System, Pregnancy & Allergies

10. Do you have a condition or use any medications that cause a weakened immune system? *

Yes

11. If yes, what is the cause of your weakened immune system?

12. Is there a possibility you might be pregnant?

Yes

Not Applicable

13. Do you have any allergies?

Yes

14. If yes, please list any allergies and what reaction you get with them

Appointment Availability

15. Are you able to come into the Pharmacy for an appointment?

Yes

16. If yes, please tell us when you are available during our opening hours

17. If no, please tell us the best times to contact you

Consent

15. 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.