Pharmacy First Shingles Consultation

Patient Acknowledgement

By completing this consultation you agree to YourPharmacy’s Terms and Conditions and Privacy Policy.

Important Information

You must not complete this consultation if you are experiencing any of the following

If any of these apply you must call 999 immediately

Neck Stiffness or sensitivity to light.

Mottled or Blotchy Skin.

Feeling Confused.

Muscle Weakness

Loss of bladder or bowel control

Difficulty moving one side of your face

A rash on your nose

Any changes to your vision

Redness in one of both of your eyes

A severely weakened immune system

If you have any of these other conditions you must not wait for a response from us and contact your GP or 111 immediately.

You have a high temperature

Feel particularly unwell

You are pregnant, have not had the chickenpox before and have been in contact with someone with chickenpox or shingles

Treatment for shingles depends on how severe your symptoms are and whether you’re at risk of complications. If you have a mild rash you do not need treatment.

For more information on managing shingles please click here: https://www.nhs.uk/conditions/shingles/

I agree to the terms and I confirm none of the listed conditions apply to me

Name(Required)

These must match your NHS file

First Last

Date of Birth(Required)

What is your gender(Required)

This much match your NHS file

NHS number (if known)

Email Address(Required)

Phone Number(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

Along with a rash, have you had of the following symptoms?(Required)

Tingling or itchy feeling in the skin

Pain or burning feeling in the skin

Feeling feverish

None of the above

Where on your body is the rash?(Required)

How long have you had the rash?(Required)

Less than 3 days

3-5 days

5-7 days

More than 7 days

How would your pain on a scale of 0-10?(Required)

Here 0 means no pain and 10 means severe pain

Please select the statement that best suits your circumstance.(Required)

I am pregnant

I’m trying to conceive

I am breastfeeding

None of the above

Have you had shingles before?(Required)

Yes

I’m not sure

What have you tried to manage your symptoms?(Required)

Do you have any allergies?(Required)

Yes

Please specify more details(Required)

Please list any allergies and the reactions you have.

Are you able to take clear photos of your rash?(Required)

Yes

I’m not sure

Upload a photo(Required)

Tips for taking a good photo

Make sure you have adequate lighting

Make sure the subject is clear and in-focus

Drop files here or

Max. file size: 256 MB, Max. files: 5.

One of our pharmacists may need to contact you whilst they are processing your consultation, when would be the best time to contact you?

We can’t guarantee a time and will only contact you during opening hours, (Mon – Fri, 9am to 5pm)

Patient Agreement

By completing this consultation you agree to the following:

You answered all the questions correctly and to the best of your ability

You consent to YourPharmacy contacting you via phone or email to ensure the best possible care

You confirm you do not NEED URGENT medical attention, if so ring 999.

I agree

Pharmacy First Sore Throat Consultation

Patient Acknowledgement

By completing this consultation you agree to YourPharmacy's Terms and Conditions and Privacy Policy.

Important Information

You must not complete this consultation if you are experiencing any of the following

If any of these apply you must call 999 immediately

Difficulty breathing or swallowing.

Breathing that sounds abnormal or high-pitched.

A muffled or hoarse voice drooling.

If you have any of these other conditions you must not wait for a response from us and contact your GP or 111 immediately.

A weakened immune system

You are not producing as much urine as usual.

Feeling to unwell to care for yourself, for example simple tasks like washing or making food.

A fever with feeling generally weak, dizzy or excessively tired

I agree to the terms and I confirm none of the listed conditions apply to me

Name(Required)

These must match your NHS file

First Last

Date of Birth(Required)

What is your gender(Required)

This much match your NHS file

NHS number (if known)

Email Address(Required)

Phone Number(Required)

Address(Required)

Street Address City ZIP / Postal Code Country

How long have you had as sore throat?(Required)

Have you felt feverish in the past 24 hours?(Required)

Yes

Have you checked your temperature recently?(Required)

Yes

Please enter the reading below (°C)

Do you have a cough?(Required)

Yes

How long have you had the cough?(Required)

Do you have a blocked or runny nose?(Required)

Yes

Do you have a rash or does your skin feel rough, like sandpaper?(Required)

Yes

I'm not sure

Upload a Photo(Required)

Tips for taking a good photo

Make sure you have adequate lighting

Make sure the subject is clear and in focus.

Drop files here or

Max. file size: 256 MB, Max. files: 3.

Do you have any allergies?(Required)

Yes

Please specify more details(Required)

Please list any allergies and the reactions you have.

Do you have a condition or use any medications that cause you to have a weakened immune system?(Required)

For example, receiving chemotherapy, long-term steroid treatment, or have an underlying condition such as leukaemia or HIV.

Yes

What is the cause of your weakened immune system?(Required)

Please select the statement that best suits your circumstance.(Required)

I am pregnant

I'm trying to conceive

I am breastfeeding

None of the above

One of our pharmacists may need to contact you whilst they are processing your consultation, when would be the best time to contact you?

We can’t guarantee a time and will only contact you during opening hours, (Mon - Fri, 9am to 5pm)

Patient Agreement

By completing this consultation you agree to the following:

You answered all the questions correctly and to the best of your ability

You consent to YourPharmacy contacting you via phone or email to ensure the best possible care

You confirm you do not NEED URGENT medical attention, if so ring 999.

I agree