Questionnaire - Smart Allergy Solutions

Are you eligible?

Before you can register we need to ask you some questions to find out if you are eligible for our treatment.

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Do you suffer from hayfever/nasal symptoms at any of the times below?

February to April (Typical of tree pollen allergy)

April, May, June or July (Typical of grass pollen allergy)

Bothersome all year round, or worse in Winter months (Typical of HDM allergy)

Do allergy medications provide incomplete relief?

Yes

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Please select an option

You may benefit from immunotherapy, now we just need to check some medical details

By checking the boxes below you are confirming you:

(If you are unsure of the answer please discuss with your GP)

Do not have a long term infectious condition

e.g. HIV, tuberculosis (if do not wish to state on form please contact our office)

Are not currently undergoing treatment for cancer

Are not on any of the following medications:

Immunosuppressants - e.g. Methotrexate, Cyclosporine, Azathioprine
Beta Blockers - e.g. Atenolol, Bisoprolol, Propanolol, Sotolol

Have not ever had a serious of life-threatening allergic reaction, sometimes called ‘anaphylaxis’

Have not been diagnosed with an autoimmune condition

e.g. under or over active thyroid, vitiligo, rheumatoid arthritis, Crohn’s or ulcerative colitis.

If you are unable to tick all boxes you are currently unsuitable for immunotherapy, please visit your GP.

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Alert: To be eligible to proceed you need to tick all of the above boxes

Just a few more details

Immunotherapy is suitable for most patients but guidelines recommend it should be avoided in a small number of people. Please answer the questions below:

Have you had desensitisation or immunotherapy treatment (such as injections) for this allergy before that needed to be stopped because of side effects or unwanted reactions?

Yes

No
Are you pregnant or considering becoming pregnant in the near future (immunotherapy should not be started during pregnancy but may be continued if you become pregnant during treatment)

Yes

No

Please answer all the questions

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Congratulations, you are eligible for our treatment

Now we will just need some of your details

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Unfortunately you are not eligible to apply for our treatment

At this time, based on the answers you have provided, you are not eligible for our treatment.

You can log in and try again in the future should your condition change.

If you would like to speak to a specialist about your condition please contact Allergy London to make an appointment with Dr. Adam Fox or Prof. Stephen Till.

www.allergylondon.com

Request completed

Thank you for selecting for your consultation.

A member of their practice team will contact you within the next couple of days to arrange a suitable time for your consultation.

We have also sent a confirmation email containing your order and payment details to:

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