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Respiratory Assessment – Walk IN

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– Step 1 of 2

Name *

First

Last

Please note to qualify for treatment:

Patients must be16 years of age and ove.

Patients must have seen their GP or nurse in the last year and have had a salbutamol 100mcg MDI inhaler prescribed for them within the last year.

Do you have any recent or past medical history of note? *

Yes
No

If yes, please provide details

Do you have a medical history of the following: heart conditions (cardiovascular disease) such as arrythmias, susceptibility to prolonged QT-interval or hypertension; hypokalaemia, hyperthyroidism, diabetes? *

Yes
No

If yes please provide details

Have you had a doctor/nurse asthma review within the past year? *

Yes
No

Is your asthma controlled well with your current medical regime? *

Yes
No

Within the past year, have you been prescribed salbutamol? *

Yes
No

If not, please list the name of the medicine

Have you had a serious reaction to a medicinal inhaler before? *

Yes
No

If yes, please provide details

Do you know how to use your inhaler properly? *

Yes
No

Do you use your inhaler more than two puffs, four times a day? *

Yes
No

Please list your symptoms below

Please list all your current prescription medication including any medication you buy over the counter

Please write below any further information which may be relevant

Complete Patient Details

Title *

Mr
Miss
Ms
Mrs
Other

Patients Name *

First

Last

Layout

Date of Birth (DD/MM/YYYY) *

Age

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient Consent *

I agree that my Summary Care Records willl accessed to confirm medication history with the GP.
I agree that my GP will be notified about this cosultation
I agree to read the patient information leaflet contained within the box of the salbutamol inhaler
I agree to seek further medical help if my asthma does not improve within an hour after my first dose

Patient ID *

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Start Assessment

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- Step 1 of 3

Patient Name *

First

Last

Parent or guardian name if applicable

First

Last

Have you had a serious reaction to any acne treatments before? *

Yes
No

If yes, please describe the product and the reaction

Do you have any allergies? *

Yes
No

If yes, please provide details

Are you pregnant, planning pregnancy, or is there any possibility that you could be pregnant? (copy) *

Yes
No

Are you breast feeding? *

Yes
No

Have you started puberty? *

Yes
No

Are you willing to use contraception for at least 1 month before starting treatment, during treatment, and for at least 1 month after stopping treatment? *

Yes
No

Do you have perioral dermatitis (redness and soreness around your mouth) or rosacea? *

Yes
No

Are you currently using any other treatments for acne? *

Yes
No

Have you recently received an acne treatment containing antibiotics? *

Yes
No

If yes, please list the product and date you received it

If you have used acne treatments before, did you experience any side effects or skin irritation? *

Yes
No

If yes, please provide details

Do you have a history of photo-allergy (skin reactions in the sunlight)? *

Yes
No

Do you have, or have you had any of the following? ̵ Regional enteritis (crohn's disease) ̵ Ulcerative colitis (inflamed colon and rectum) ̵ Inflammatory bowel disease or antibiotic-associated colitis (including pseudomembranous colitis) *

Yes
No

Have you or any of your close family had skin cancer? *

Yes
No

Do you currently have sunburn, broken skin or abraded skin? *

Yes
No

Do you have any allergic diseases such as asthma, eczema or rhinitis? *

Yes
No

If yes, please provide details

Do you have any liver or kidney problems? *

Yes
No

If yes, please provide details (copy)

Are you currently using any cosmetics, medicated cleansers or scrubbing solutions? *

Yes
No

Do you suffer from severe psychological distress because of your acne? *

Yes
No

Have you undergone or recently undergone procedures such as depilation, chemical hair treatments, chemical peels, dermabrasion, laser resurfacing of the skin or phototherapy? *

Yes
No

Are you sensitive to sunlight or do you have considerable sun exposure? *

Yes
No

Please list all your current prescription medication including any medication you buy over the counter

Please provide details of any recent or past medical history of note (e.g. other conditions you have been treated for)

Complete Patient Details

Title *

Mr
Miss
Ms
Mrs
Other

Patients Name *

First

Last

Date of Birth (DD/MM/YYYY) *

Email *

Phone

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

GPs Name & Address

Patient GP Consent *

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Patient Consent (Other) *

I am happy to access treatment from Tabi Health Clinic and not from my GP
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Click to view pharmadoctor terms & conditions.

Patient ID *

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

Choose type of consultation required *

Walk In (done in the clinic, based in Hitchin SG4 9TH)
Online (via video consultation)