allergy test part a

8/10/2019 Allergy Test Part A

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MEDICAL EXPRESS CLINIC

ALLERGY QUESTIONNAIRESection A: Health andLie!t"le Q#e!tionnai$e

and Alle$%" E&al#ation'

IT(S ALL A)OUT YOU AND YOUR ALLERGIES

Please give us as much details as possible.There are Male and Female questions, please fill those as appropriate. There are questionnaire on sex andsexuality, also and may appear intrusive. If you wish not to answer any section or any questions,please leave blan. Than you.If you wish to give more information, please feel free to write them. Than you.

A' PERSONAL DETAILS

Forename! """""""""""""""""""""""""""""""" #urname! """""""""""""""""""""""""""

Title! Mr Mrs $r Professor #ir Madam %ther, state""""""""""""""""""

$ate of &irth! """"""""""""""""" 'ountry of &irth! """"""""""""""""""""" Date Month Year

(ddress )where your report will be sent*!""""""""""""""""""""""""""""""""""""""""""

"""""""""""""""""""""""""""""""""" Postcode! """""""""""""""""""""""""""""

$aytime telephone! """"""""""""""""""""""""" Mobile! """""""""""""""""""""""""""""

+vening telephone! """""""""""""""""""""""""" +mail!""""""""""""""""""""""""""""""

-ave you had any allergy test before /o 0es

If yes was it at our clinic 0es /o,please state where and when! """""""""""""""""""""

$o you have the allergy test report 0es /o

/ote! If you had any tests, in particular allergy tests before, please bring the report for review. Than you.

)' OCCUPATIONAL HISTORY

(re you now 1 #tudent 2ooing for wor -ome person 3oring person

Pensioner

%ther

please state"""""""""""""""""""""""""""""""""""""""""""""

If not woring have you ever wored 0es /o If yes, please continue with the next questions. If no, please go to #ection '. )medical history*

(re you woring at present 0es /o If no, what was your last 4ob """"""""""""""""""""0our occupation! """""""""""""""""""(re you aware of any occupational health ha5ards or allergy including environmental allergies or toxins

associated with your wor /o 0es

If yes, please state! """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""

%ctober 6789 -ealth M%T 1 Promoting longevity 'opyright! Professor #am 2ingam

$r. Mohammad &ahtiar

1


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If you wish to state anything about your 4ob, which we should be aware, please state here"""

C' MEDICAL HISTORY

8. Please state any serious illness or ma4or surgery you have had in the past )give approximate dates*!

6. (re you currently suffering from any illness, allergy or anaphylaxis /o 0es

If yes, please state details! """"""""""""""""""""""""""""""""""""""""""""""""""""""

9. If you have allergy 0es /o, please fill the (llergy :uestionnaire, later in this :uestionnaire.

;. $o you have any allergy or allergy history for medication, drugs or bee sting etc.! 0es /o

If yes, please state! """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""

. -ave you ever had a mental health problem /o0es #ome mental health problems )including

depression* can be due to allergies. ?ead a boo 1 /ot all in the mind by ?ichard Macanus, a consultant

psychiatrist. If yes, is it! $epression (nxiety $isorder Panic attac

or other, please state! """"""""""""""""""""""""""""""""""""""""""""""""""""""""""

2%ctober 6789 -ealth M%T -elping to remain young longer 'opyright! Professor #am 2ingam $r. Mohammad &ahtiar


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D' RELATIONSHIP STATUS

,I "o# do not eel co.o$ta/le illin% thi! !ection0 1lea!e lea&e it /lan2 and tic2 he$e-

Please indicate your @personalA relationship status at the present time!

#ingle Married 2ong Term ?elationship $ivorcedB#eparated 3idowed 'ohabiting

%ther state! """"""""""""""""""""""""""

For how long have you been in this personal relationship status """"""""""""""" monthsByears

Please state any significant changes to your relationship status in the last < years! """""""""""""

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

(re you! &isexual -omosexual 2esbian %ther, state!""""""""""""""""""""""

I c#$$entl" in a $elation!hi1:

$etails of the partner )if it is o with your partner*! /ame! """"""""""""""""""""""""""""

$ate of &irth"""""""""""""""""""""""

Is your partner in good health 0es /o

$o you consider that you are in a stable relationship 0es /o

$o you feel your relationship causes you stress more often than not /o 0es

$o you feel your relationship is stable and supportive 0es /o

(re you happy and fulfilled in this partnership 0es /o

$o you feel you have adequate support from family and friends 0es /o

Is there anything you want to tell us about your relationship /o 0es If yes, state""""""""

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

E' PERSONAL LI*E HISTORY

Child$en

-ave you any children /o 0es If yes, write in your childrenCs ages if applicable.)if more than ; children, write in a separate sheet* . If any of your children have allergies state.

'hildCs /ame $ate of &irth #ex &irth

3eight

#tate of

-ealth and

(llergies

8.

6.

9.

;.

$o your children have any significant medical or educational problems /o 0es If yes, state!"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""



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+o.en onl" an!3e$ the ollo3in% 4#e!tion!'

3omen with allergies may have fertility problem, early menopouse and miscarriages.

$id you have any termination of pregnancy for medical reasons /o 0es If yes, state! """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

$id you have any miscarriage )of pregnancy* /o 0es If yes, state! """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

(re you in menopause /o 0es if yes, at what age """"""""""""

(re your period regular /o 0es if not, what is the problem """""""""""""""""""

*a.il" Hi!to$"

If you have been adopted, fostered or other, please tic one of the following boxes below!

Fostered (dopted %therIf other, please give details"""""""""""""""""""""""""

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

If you have not been adopted, fostered or other please write in your relativesA details.

0our family history!)if more than 6 brothersBsisters, write in a separate sheet*

?elation (ge #tate of -ealth If $ead,

(ge at $eath

If $ead,

'ause of $eath

Father

Mother&rother

&rother

#ister#ister

$o you have )or did you have* any blood relatives with health problems )i.e. high blood pressure, heart

problems, stroe, diabetes, cancer or thyroid disorder* /o 0es If yes, state! """"

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

$o you have )or did you have* any close relatives who had cancer /o 0es if yes, please

state! """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""



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*' PERSONAL LI*ESTYLE

*'5 S.o2in%

-ave you ever smoed /o, I never smoed pleasego to the last two questions mared D

I used to smoe, but I stopped years ago B months ago

0es, I smoe I started to smoe at years of age.

If you smoe, how many cigarettesBcigarsB pipe do you smoe at present

'igarettes per day cigars per day pipe per day

(re you aware that smoers should have regular chest Eray to loo for lung cancer 0es /o

If yes, when was your last chest xray """""""""""""""""""""""""""""""""""""""""""

3ould you lie to quit smoing 0es /o $iscuss with the doctor.

3ould you lie to have hypnosis or acupuncture treatment at our clinic privately /o 0es

D If you do not smoe, are you a regular passive smoer /o 0es

D (re you aware of the effects of passive smoing 0es /o

)Please see our website @www.medicalexpressclinic.comA at the #ection to get adviceon how to quit smoing*

*'6 Alcohol

-ave you ever drun alcohol /o, I am a teetotaller pleasego to the last two questions mared D

I used to drin alcohol, but I stopped years agoB months ago

0es, I drin alcohol

If you are a driner, what do you usually drin &eer 3ine #pirit %ther, state! """""""

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

-ow many units of alcoholG do you drin per day units)If you do not now what a unit of alcohol is, please see the footnote at the bottom of the page*

-ow many days a wee do you drin that quantity days

-ow many units of alcohol do you drin a wee units

(re you aware that food slows alcoholAs absorption and effects )no cardiovascular benefits*0es/o

If no, will you try to eat while drining alcohol now 0es /o



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-ave you ever thought about cutting down your drining 0es /o

-ave you ever been annoyed by criticism on your drining 0es /o

-ave you ever felt guilty about your drining 0es /o

$o you drin in the morning )as soon as you wae up* 0es /o

(re you aware of the harmful effects of alcohol to the baby if a pregnant woman drins 0es/o

(re you aware of the health effects of drining alcohol 0es/o

0ou also can see advice on alcohol in the #ection.of our website! www.medicalexpressclinic.com

*'7 E8e$ci!e

$o you regularly play sports or tae exercise /o

0es

If yes, please specify """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

$o you tae 97 minutes exercise per day for at least five days a wee, as recommended 0es/o

$oes the exercise maes you go out of breath 0es/o

(re you aware of the benefits of exercise for health 0es/o

If you would lie to read more about the good effects of exercise for health, please visit our website at the #ection

8. %ne unit of alcohol corresponds to half a pint of ordinary strength beerBciderBlager )such as &udweiser or 'arlsberg*Hone quarter of a pint of strong beer, cider or lager )such as #tella*H one small glass of wine )867 ml*H one single )pub 6< ml*measure of spiritsH one small glass of sherry.

*'9Diet

$o you consider your diet to be healthy 0es/o

$o you have any food allergies /o

0es

If yes, state details! """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

(re you vegetarian /o0esIf yes, is it from birth or from when! """""""""""""""""""

(re you on any special diet /o0esIf yes, state details! """"""""""""""""""""""""""""

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

-ow many portions of fruit do you eat a day 7 8 6 9 ;


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-ow many cups of tea or coffee do you drin per day 7 8 6 9 ;


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$o you mae efforts to cut salt in your diet 0es/o

$o you tae any vitaminBmineral supplements /o0esIf yes, please write which ones and from

when! """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

'offee! how many cups of coffee do you drin a day on average$o you now that 6 to < cups of coffee a day is good for cardiovascular health $rining more thanthat is not beneficial.

Is there anything else you would lie to tell us about your dietBnutrition /o0esIf yes,

please state details"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""0ou can find advice on dietBnutrition for health in our website at the #ection

6 %ne portion of fruit corresponds to one apple or banana or pear or two slices of pineapple or a small bowl of fruits.9. %ne portion of vegetables corresponds to two tablespoons of vegetables or one dessert bowl full of salad.

*' Slee1

$o you have sleep problems /o0esIf yes, please state details""""""""""""""""""""""""

""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

$o you snore during sleep )as your partner if you snore* /o 0es

$o people tell you that you snore /o 0es -as anyone ever told you that you gasp for breath when you sleep /o 0es

)$o you now that we have a symbiotic relationship with a sleep clinic in the same building If you are interested, as for

details or visit sleeprhythmstresscentre.com or bocsleepcentre.com*

*'; St$e!!

%ctober 6789 -ealth M%T 1 $etecting medical problems sooner 'opyright! Professor #am 2ingam

to improve health and longevity $r. Mohammad &ahtiar

-ow many times a wee do you eat 7 8 6 9 ; $o you now anyone in your family who had anaphylaxis /o0es



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-. Is there anything else you want to tell us about your allergy /o0es

if yes to any questions please give details """"""""""""""""""""""""""""""""""""""""

5' A!th.a and Rhiniti!

There are atopic conditions, often trigged by allergies to food or environmental substances.

These include house dust mite, pollens, moulds etc. #in 1 pric 1 test can help to identify the

triggers.

5'5 A!th.a and Che!t Inection!

8.8.8$oes anyone close in your family have )had* rhinitis or asthma

8.8.6$id you have asthma ever /o0esIf yes, please state details"""""""""""""""""""""""""""

8.8.9$id you have a lot of chest infections /o0es If yes, please state details """""""""""""""

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

5'6 S.o2in% ,S.o2in% i! the /i%%e!t $i!2 acto$ o$ de&elo1in% a!th.a and COPD-

$o you smoe, now /o0es If yes, please state details """"""""""""""""""""""""""""""""""

"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

$id you smoe ever /o0es If yes, please state details """""""""""""""""""""""""""""""""

-ow many years did you smoe in total""""""""""""""""

-ow many cigarettes per day on average did you smoe )smoing is not only cause of lung cancer, it triggers

asthma and is an important cause for '%P$ and myocardial infarctheart attac.*

6' ASTHMA AND COPD SYMPTOMS

6'5 Co#%h

6.8.8 $o you have cough in the night /o0es If yes, please state details""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

6.8.6 $o you have cough first thing in the morning /o0es If yes, please state details""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

6.8.9 $o you bring up sputum /o0es If yes, please state details"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

6.8.; $o you whee5e /o0es If yes, please state details""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

6'6 Sho$tne!! o /$eath

6.6.8 $o you get short of breath when waling )while others wal easily* /o

0es



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6.6.9 $o you get short of breath when you climb up a few steps )while others climb them without any

difficulties* /o0es

7' TESTS

7'5 L#n% *#nction Te!t ? S1i$o.et$" )please discuss with the nurse*

9.8.8 -ave you ever had #pirometry or Pea flow (ssessment 0es/o If yes, what was your

best pea flow """"""""""""

If you never had a pea flow measurement and lie to have one now, please tic this box . 0ou will need to

pay U


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This clinic is run by an experienced doctor woring in this area of medicine. The doctor will assess you

and will suggest treatment option with you. 0ou can arrange to attend this clinic 1 you pay U>

instead ofU9


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RP@s name )where your report will be sent*!

""""""""""""""""""""""""""""""""""""""""""""""""

(ddress! """"""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

"""""""""""""""""""""""""""""""""""""""""""""" Postcode! """""""""""""""""""""

If you are under a consultantBspecialist state details if you wish us to send a copy of the report

/ame of specialist! """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""

(ddress! """""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""" Postcode! """""""""""""""""""""

$o you wish us to send a copy of the report to your specialist 0es/o

5'This is #ection (! -ealth and 2ifestyle :uestionnaire with (llergy :uestionnaire. Please fill section&! Medical +xpress 'linic Medical :uestions! 0our -ealth )attached to this questionnaire*.

6'If you are attending for (llergy testing and you are having #inPricTest, please thin inadvance what allergens you would lie to have the #in 1 Pric 1 Test carried out with. 0ou arewelcome to bring your own allergens.

0ou will have standard two pric tests. +veryone will have this. a* -istamine as positive control b* #aline as negative control

0ou can write down up more allergens you wish to have tested )a total of 87 tests*.

W Please see the list of allergens we have. /ow we have


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3e will try and answer your questions.3e will try and meet your expectations.Please note that we can do lot more testsH measure your vitamin levels, chec your blood for anaemia,iron deficiency, thyroid problems, and idney and liver function abnormalities.3e can chec you for diabetes or prediabetis.%ur usual price for such tests is U7XU9.(s the nurse at reception and have the blood test today at this bargain price.3e can do 2actase intolerance test by breath tests.

3e can do Ig+ mediated specific antibodies in blood and now IgR mediated specific test. Please readabout these tests. (s us if you wish to have these done.3e have test for coeliac disease 1 blood test.

allergy test part a

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