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. Along with a rash, have you had any of the following symptoms?
Tingling or itchy feeling in the skin
Pain or burning feeling in the skin
Feeling feverish
2. Where on your body is the rash?
Enter text.
3. How long have you had the rash?
Choose all that apply (you can select none)
Less than 3 days
3-5 days
5-7 days
More than 7 days
4. How would you rate your pain on a scale of 0-10?
Here, 0 means you have no pain and 10 means severe pain
Boxes 0-10 to select one option from
5. 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
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
Unexplained red eye(s)
6. Please list any pre-existing conditions
Enter text.
7. 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 7 they will see question 8, if they answer no they skip to question 9👇
8. What is the cause of your weakened immune system?
Enter text.
9. Is there a possibility you might be pregnant?
Yes
No
Not applicable
10. Are you currently breastfeeding?
Yes
No
Not applicable
11. Have you had Shingles before?
Yes
No
I'm not sure
12. What have you tried to manage your symptoms?
Enter text.
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 take clear photos of your rash?
Yes
No
I'm not sure
If the patient answers yes to question 15 they will see question 16, if they answer no or i'm not sure they skip to question 17👇
16. Upload a photo
Tips for taking a good photo:
- Make sure you have adequate lighting
- Make sure the subject is clear and in-focus (the image has crisp edges)
- Where appropriate place a ruler or coin in the photo to provide a sense of scale
Upload up to 5 images.
17. 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. 👉