What does this Questionnaire do?
Pharmacies can offer advice and treatment for urinary tract infections (in women), new sinus problems, sore throats, ear infections, infected insect bites, impetigo and shingles, without a GP appointment or prescription.
The questionnaire link is sent via SMS or email. The patient fills in the questionnaire through a browser so they can use their phone, tablet, laptop or desktop to complete it.
The responses are returned to the user or organisation via the Accurx Web inbox. They can also be assigned to other colleagues.
Questions:
1. How long have you had a problem with your ear(s)?
Less than 3 days
More than 3 days
2. Which ear(s) are affected?
Right ear
Left ear
Both ears
3. Do you have any of the following symptoms?
Choose all that apply (you can select none)
Pain in the ear(s)
Fluid coming from the ear(s)
Hearing loss or a change in hearing
Fever
Cough
Holding, tugging or rubbing the ear
Runny nose
Reduced food or fluid intake
Feeling restless or crying
4. Do you have any of the following symptoms?
Choose all that apply (you can select none)
Neck stiffness or sensitivity to light
Mottled or blotchy skin
Swelling or pain behind the affected ear(s)
Severe headache
Feeling irritable or confused
Weakness in the arms or legs
Facial dropping
Pain behind or around the eyes
5. Do you think your symptoms are improving?
Yes
No - they are the same
No - they are getting worse
6. How many ear infections have you had in the past 6 months?
0
1
2
3
4 or more
7. Have you tried anything to manage your symptoms?
For example, nasal sprays, pain relief or antibiotics.
Enter text.
8. Please list any medical conditions you have below
Please include any heart, lung, liver or muscle problems
Enter text.
9. Were you born prematurely?
Premature or pre-term birth refers to birth before 37 weeks
Yes
No
Not sure
10. Do you have a condition or use any medications that cause a weakened immune system?
For example, receiving chemotherapy, long-term steroid treatment, or have an underlying condition such as leukaemia or HIV
Yes
No
If the patient answers yes to question 10 they will see question 11, if they answer no they skip to question 12👇
11. What is the cause of your weakened immune system?
Enter text.
12. Is there a possibility you might be pregnant?
Yes
No
Not applicable
13. Do you have any allergies?
Yes
No
If the patient answers yes to question 13 they will see question 14, if they answer no they skip to question 15👇
14. Please list any allergies and what reaction you get with them
Enter text.
15. Are you able to come into the Pharmacy for an appointment?
The pharmacist needs to see you in person to decide what treatment you need
Yes
No
If the patient selects yes to question 15 👇
16. Please tell us when you are available during our opening hours?
Enter text.
If the patient selects no to question 15 👇
16. Please tell us the best times to contact you
We can’t guarantee a time and will only contact you during opening hours
Enter text
When they have submitted their answers, they will be thanked for completing the questionnaire and given some safety netting information 👇
If you still have any questions or concerns, feel free to chat with us using the green message bubble in the bottom right-hand corner of this page. 👉