RAF - Sore Throat - Penicillin

Sore Throat Assessment Form
Patient Information
Patient Name*

First NameLast Name
Date of Birth*

DayMonthYear
Gender*

FemaleMale
Address*

First Line of Address

Street Address 2

CityCountry

Postcode
Email*
Please check your email address is correct
Phone Number*
Medical History
If you have any severe symptoms, such as a difficulty breathing, chest pains, slurred speech, extreme shivering, muscle pain or passing no urine, please do not use this service and call 111 or 999 without delay.*
Are you or is the patient over the age of 1?*

YesNo
Do you have any allergies?*

YesNo
Please specify*
Have you had a serious reaction or intolerable side effects to penicillin, clarithromycin, other macrolides or any other medications before?*

YesNo
Have you been told by your doctor you have an intolerance to any sugars (e.g. fructose intolerance)?*

YesNo
Are you pregnant, planning pregnancy is there a possibility you may be pregnant?*

YesNoN/A
Are you breast-feeding?*

YesNoN/A
Have you previously suffered from an infection (Clostridium difficile) after being treated with antibiotics or do you have a history of antibiotic-associated colitis?*

YesNo
Are you undergoing long term phenoxymethylpenicillin (penicillin V) treatment?*

YesNo
Are you planning on receiving vaccination with the oral typhoid vaccine (Vivotif) or have you completed vaccination in the last 10 days?*

YesNo
Please tick the options which apply to you:*

Absence of coughFever in last 24 hours (over 38°C)Severe tonsil inflammationSwollen lymph nodes (lumps) in the neck and under the jawWhite spots or pus on tonsilsSymptom onset ≤3 daysOther (please specify)
FeverPAIN score
How many days have you had the symptoms for?*
Do you have any of the following symptoms:*

Difficulty breathingDifficulty swallowing with signs of obstructionConfusion/disorientationDiarrhoeaMuscle painDizzinessNone of the above
Do you have any of the following conditions:*

Severe empyemaBacteraemiaPericarditisMeningitisInfectious arthritisNone of the above
Do you have a history of rheumatic fever?*

YesNo
Are you suffering from any gastrointestinal problems (e.g. nausea, vomiting, diarrhoea, intestinal hypermotility, cardiospasm, gastric dilation, etc.)?*

YesNo
Do you have any liver or kidney problems?*

YesNo
Please specify*
Do you have any heart problems, QT prolongation, or have you had a heart attack previously?*

YesNo
Do you suffer from asthma, eczema or hay fever?*

YesNo
Please specify*
Are you on a low potassium diet?*

YesNo
Do you have any problems with the levels of salts in your blood (electrolyte imbalance)?*

YesNo
Do you have any other recent or past medical history of note (e.g. other conditions you have previously been treated for)?*

YesNo
Please specify*
Do you take any current or repeat medicines, including any medication or herbal supplements you buy over the counter?*

YesNo
Please specify*
This medication may not be suitable for you, please contact us for further advice, by email: info@myprivatechemist.com, or phone: 02039879202.
Please note, a Strep A test using a throat swab will need to be undertaken at the clinic to confirm a diagnosis.*
Appointment Booking
Collection from:

My Private Chemist

Longcroft House

2-8 Victoria Avenue

EC2M 4NS
Should be Empty:

Sore Throat Assessment Form

Patient Information

Medical History

Appointment Booking