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Your Health

About You

Do you believe you have the capacity to make decisions about your own health; and that you do not require help to complete this consultation? *

Yes

What is your height? *

feet/inches

cm *

What is your weight? *

stones/lb

kg *

Stone *

Have you been diagnosed by your GP as having allergic rhinitis or hay fever? *

Yes

Your symptoms

Are you currently using anything to treat your symptoms? *

Yes

What symptoms do you usually experience? *

What best describes the timing, frequency and persistence of your symptoms? *

Seasonal – Symptoms occur at the same time each year in response to a seasonal allergen. i.e. symptoms caused by pollen (known as hay fever)

Perennial – Symptoms that occur throughout the year (typically due to allergens from dust mites and animals/pets)

Intermittent – Symptoms occur for less than 4 days a week or for less than 4 consecutive weeks. Symptoms are usually caused by allergens such as animals (pets)

Persistent – Symptoms occur for more than four days a week and for more than four consecutive weeks

Occupational – Symptoms occur due to exposure of allergens in the work place

Other

What causes your symptoms? *

Do your symptoms affect your quality of life? i.e. Affect your sleep, concentration, mood, behaviour etc. *

Yes

Are you currently experiencing any of the following? *

Yes

Sudden onset of symptoms
Nasal discharge that is NOT clear in colour
Fever
Loss of taste or smell time
Nasal congestion after having stopped using a nasal decongestant or after having used a nasal decongestant for a long period of time
Nose bleeds
Pain in your nose or your nose differing in appearance
Problems with your eyes such as pain, change in vision, discharge, dislike of bright lights
Symptoms only affecting one side of your face i.e. one of your nostrils, one of your eyes, one side of your face, nasal discharge or bleeding from one nostril only
Any other changes to your health

Your health

Are you pregnant, breast feeding, planning pregnancy, or at risk of pregnancy whilst taking this medication? *

Yes

Pregnancy risk may be defined as late period or unprotected sexual intercourse which may have taken place since your last normal period.

Do any of the following apply? You have: *

Yes

An untreated infection in your nose
An injury or trauma to your nose
Recently had nasal surgery or trauma that has not healed
A problem with your immune system
Pulmonary tuberculosis

Do you have any other medical conditions? *

Yes

Your Medication

Are you taking any medication or recreational drugs? *

Yes

Do you have any allergies? *

Yes

Agreement

Do you understand that you should stop using this medication and seek urgent medical advice if you experience: *

Yes

Swollen face, tongue or throat
Trouble swallowing
Hives
Wheezing
Trouble breathing
Any other unusual side effects

Whilst you should seek urgent medical advice, you should also inform your GP and inform us if you experience any of the above, or any other side effects. You should call 999 in the case of a medical emergency, or 111 for advice.

Are you aware that if you have moderate-to-severe persistent symptoms: *

Yes

You should use treatment during periods of allergen exposure, and/or when symptoms are present
The onset of action is a few hours after the first dose, but the maximal effect may not be seen until after a few weeks
You should not use more than your prescribed dose as there is no evidence of additional benefit from using more than prescribed

Are you aware that? *

Yes

You can visit Allergy UK to find out more about hay fever (allergic rhinitis), and the NHS website to find out more about allergic rhinitis and hay fever
You should consider using nasal irrigation with saline as a non-prescription intervention, which can be bought over the counter
If grass pollen causes your allergy, you should avoid walking in grassy open spaces when the pollen count is high; avoid drying washing outdoors when pollen count is high, keep windows shut in cars and buildings, plan holidays to avoid the pollen season, shower and wash hair following pollen exposure
If you have a house dust mite allergy you should use synthetic pillows and acrylic duvets and keep furry toys off the bed; wash all bedding and furry toys at least once a week at high temperatures; choose wooden or hard floor surfaces instead of carpets where possible; fit blinds instead of fabrics where possible; clean surfaces with a damp cloth regularly
If you have an allergy to animals or pets, try to keep the animal out of the house. If this is not possible, try to restrict their presence to the kitchen. You should wash the animal and any surfaces they are in contact with, regularly.
If you have an allergy because of your occupation, you should eliminate or reduce exposure to allergens in the workplace, for example, use latex-free gloves, wear protective clothing, or a face mask; you should ensure that your work environment is adequately ventilated or relocate to an area of low exposure in the workplace; use less hazardous chemicals if appropriate and where possible.
Treatment is unlikely to affect your ability to drive or operate machinery. However, you should check that these tablets do not make you feel sleepy or dizzy before driving or operating machinery.
If symptoms do not improve with treatment, you should contact us or your GP for further advice

Is there any additional information you would like to provide, or any questions you have? *

Yes

Do you agree that? *

Yes

You will read the Patient Information Leaflet supplied with your medication. You should report any side effects and changes in your health and body to your GP, and via the Yellow Card Scheme
You will contact us and inform your GP if you experience any side effects of treatment, if you start new medication or if your medical conditions change during treatment.
You are over 18 and the treatment is solely for your own use
You have answered all the above questions accurately and truthfully and that incorrect information can be hazardous to your health
You are aware the decision about your treatment are for both the prescriber and yourself to jointly consider during this consultation, but the final decision will always be the prescriber's
You will inform your GP that you have ordered this medication
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