• New Patient Questionnaire

    This will take approximately 10 minutes to complete. It will allow us to be familiar with your history before your visit.
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    Pick a Date
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  •   Yes No
    Asthma
    Eczema
    Hives (Urticaria)
    Hay Fever
    Sinus Troubles
    Frequent Colds
    Persistent Cough
    Diarrhoea
    Abdominal Cramps
  •   Yes No
    Have you ever had a skin reaction to Jewellery?
    Have you ever had a skin reaction to Skin Care Products/Cosmetics?
    Have you ever had a Patch Test?
  •   Yes No
    Asthma
    Eczema
    Runny nose (Rhinitis)/Hay Fever
    Vomiting, Diarrhoea or Colic
  •   Yes No
    Do you have a cat?
    Do you have a dog?
    Are your symptoms better on holidays?
    Are you worse at work?
    Do you have any hobbies?
  •   Yes No
    Have you ever had an operation on your Sinuses?
    Do you have High Blood Pressure?
    Are you Diabetic?
    Do you smoke?
  • Should be Empty: