Allergy Test Part A

MEDICAL EXPRESS CLINIC
ALLERGY QUESTIONNAIRE
Section A: Health and Lifestyle Questionnaire
and Allergy Evaluation.

ITS ALL ABOUT YOU AND YOUR ALLERGIES
Please give us as much details as possible.
There are Male and Female questions, please fill those as appropriate. There are questionnaire on sex and
sexuality, also and may appear intrusive. If you wish not to answer any section or any questions,
please leave blank. Thank you.
If you wish to give more information, please feel free to write them. Thank you.
A. PERSONAL DETAILS
Forename: ________________________________ Surname: ___________________________
Title: Mr
Mrs Dr Professor Sir Madam
Date of Birth: _________________

Date
Month
Other, state__________________
Country of Birth: _____________________
Year
Address (where your report will be sent): __________________________________________
__________________________________ Postcode: _____________________________

Daytime telephone: _________________________ Mobile: _____________________________
Evening telephone: __________________________ E-mail:______________________________
Yes
If yes was it at our clinic? Yes No, please state where and when: _____________________
Do you have the allergy test report?
Yes No
Have you had any allergy test before? No
Note: If you had any tests, in particular allergy tests before, please bring the report for review. Thank you.
B. OCCUPATIONAL HISTORY
Are you now Student
Pensioner
please state_____________________________________________
Other
Looking for work
If not working have you ever worked? Yes
No
Home person
Working person
If yes, please continue with the next questions.
If no, please go to Section C. (medical history)

Are you working at present? Yes
No
If no, what was your last job? ____________________
Your occupation: ___________________

Are you aware of any occupational health hazards or allergy including environmental allergies or toxins
associated with your work? No
Yes
If yes, please state: ____________________________________________________________
October 2013
Health MOT Promoting longevity
Copyright: Professor Sam Lingam

Dr. Mohammad Bakhtiar
If you wish to state anything about your job, which we should be aware, please state here___
C. MEDICAL HISTORY
1. Please state any serious illness or major surgery you have had in the past (give approximate dates):
2. Are you currently suffering from any illness, allergy or anaphylaxis? No
Yes
If yes, please state details: ______________________________________________________

3. If you have allergy Yes
No, please fill the Allergy Questionnaire, later in this Questionnaire.
4. Do you have any allergy or allergy history for medication, drugs or bee sting etc.: Yes
No
If yes, please state: ____________________________________________________________

5. Are you currently on any medication(s)? No
MEDICATION
Yes If yes, please state details:
DOSE
FROM WHEN
WHY (INDICATION)
6. Are you at the present under any specialist or consultant for any health problem, including
allergies, at present? No Yes
If yes, please state details:____________________________
If you have any medical reports please bring or enclose them and tick here
If you have reports, but they are not available now, please tick here Please state how we can get these and
give written consent for us to obtain. Thank you
7. Have you ever had a mental health problem? No Yes
Some mental health problems (including
depression) can be due to allergies. Read a book Not all in the mind by Richard Macanus, a consultant
psychiatrist. If yes, is it: Depression
Anxiety Disorder Panic attack
or other, please state: __________________________________________________________
October 2013
Health MOT- Helping to remain young longer

D. RELATIONSHIP STATUS
(If you do not feel comfortable filling this section, please leave it blank and tick here )
Please indicate your personal relationship status at the present time:

Single
Married
Long Term Relationship Divorced/Separated Widowed Cohabiting
Other
state: __________________________
For how long have you been in this personal relationship status? _______________ months/years
Please state any significant changes to your relationship status in the last 5 years: _____________
___________________________________________________________________________
Are you: Bisexual
Homosexual
Lesbian Other, state:______________________
If currently in a relationship:
Details of the partner (if it is ok with your partner):
Name: ____________________________
Date of Birth_______________________
Is your partner in good health? Yes
No
Do you consider that you are in a stable relationship? Yes
No
Do you feel your relationship causes you stress more often than not? No
Do you feel your relationship is stable and supportive? Yes
Are you happy and fulfilled in this partnership? Yes
Yes
No
No
Do you feel you have adequate support from family and friends? Yes
Is there anything you want to tell us about your relationship? No
No
Yes If yes, state________
___________________________________________________________________________
E. PERSONAL LIFE HISTORY
Children
Have you any children? No
Yes
If yes, write in your children's ages if applicable.
(if more than 4 children, write in a separate sheet) . If any of your children have allergies state.
Child's Name
Date of Birth
Sex
Birth
State of
Weight
Health and
Allergies
1.
2.
3.
4.
Do your children have any significant medical or educational problems? No
Yes
If yes, state:
___________________________________________________________________________
October 2013

Women only answer the following questions.

Women with allergies may have fertility problem, early menopouse and miscarriages.
Did you have any termination of pregnancy for medical reasons? No
Yes
If yes, state: _____
___________________________________________________________________________
Did you have any miscarriage (of pregnancy) No
Yes
If yes, state: ____________________
___________________________________________________________________________
Are you in menopause? No
Yes
Are your period regular? No
if yes, at what age? ____________
Yes
if not, what is the problem? ___________________
Family History
If you have been adopted, fostered or other, please tick one of the following boxes below:
Fostered
Adopted
Other If other, please give details_________________________
___________________________________________________________________________
If you have not been adopted, fostered or other please write in your relatives details.
Your family history:
(if more than 2 brothers/sisters, write in a separate sheet)
Relation
Age
State of Health
If Dead,
If Dead,
Age at Death
Cause of Death
Father
Mother
Brother
Brother
Sister
Sister
Do you have (or did you have) any blood relatives with health problems (i.e. high blood pressure, heart
problems, stroke, diabetes, cancer or thyroid disorder)? No
Yes
If yes, state: ____
___________________________________________________________________________
Do you have (or did you have) any close relatives who had cancer? No
Yes
if yes, please
state: ______________________________________________________________________
October 2013

F. PERSONAL LIFESTYLE
F.1 Smoking
Have you ever smoked? No, I never smoked
please go to the last two questions marked *
I used to smoke, but I stopped
years ago
Yes, I smoke I started to smoke at
months ago
years of age.
If you smoke, how many cigarettes/cigars/ pipe do you smoke at present?

Cigarettes per day
cigars per day
pipe per day
Are you aware that smokers should have regular chest X-ray to look for lung cancer? Yes
No
If yes, when was your last chest x-ray? ___________________________________________
Would you like to quit smoking? Yes
No
Would you like to have hypnosis or acupuncture
Discuss with the doctor.
treatment at our clinic privately?
* If you do not smoke, are you a regular passive smoker? No

* Are you aware of the effects of passive smoking? Yes
No
Yes
Yes
No
(Please see our website www.medicalexpressclinic.com at the Section to get advice on how to quit smoking)
F.2 Alcohol
Have you ever drunk alcohol? No, I am a teetotaller
please go to the last two questions marked *

years ago /
I used to drink alcohol, but I stopped

Yes, I drink alcohol
months ago
If you are a drinker, what do you usually drink? Beer
Wine Spirit Other, state: _______
___________________________________________________________________________
How many units of alcohol do you drink per day?
units
(If you do not know what a unit of alcohol is, please see the footnote at the bottom of the page)
How many days a week do you drink that quantity?
days
How many units of alcohol do you drink a week?
units
Are you aware that food slows alcohols absorption and effects? (no cardiovascular benefits) Yes No
If no, will you try to eat while drinking alcohol now? Yes
October 2013
No

Have you ever thought about cutting down your drinking? Yes
No
Have you ever been annoyed by criticism on your drinking? Yes
No
Have you ever felt guilty about your drinking? Yes
No
Do you drink in the morning (as soon as you wake up)? Yes
No
Are you aware of the harmful effects of alcohol to the baby if a pregnant woman drinks? Yes No
Are you aware of the health effects of drinking alcohol? Yes No
You also can see advice on alcohol in the Section.of our website: www.medicalexpressclinic.com
F.3 Exercise
Do you regularly play sports or take exercise? No
Yes
If yes, please specify _____________
____________________________________________________________________________
Do you take 30 minutes exercise per day for at least five days a week, as recommended? Yes No
Does the exercise makes you go out of breath? Yes No
Are you aware of the benefits of exercise for health? Yes No
If you would like to read more about the good effects of exercise for health, please visit our website at the Section
1. One unit of alcohol corresponds to half a pint of ordinary strength beer/cider/lager (such as Budweiser or Carlsberg);
one quarter of a pint of strong beer, cider or lager (such as Stella); one small glass of wine (120 ml); one single (pub 25 ml)
measure of spirits; one small glass of sherry.
F.4 Diet
Do you consider your diet to be healthy? Yes No
Do you have any food allergies? No Yes If yes, state details: __________________________
____________________________________________________________________________
Are you vegetarian? No Yes If yes, is it from birth
or from when: ___________________
Are you on any special diet? No Yes If yes, state details: ____________________________
____________________________________________________________________________
How many portions of fruit do you eat a day?
1 2 3 4 5
How many portions of vegetables do you eat a day?
1 2 3 4 5
How many glasses (250ml) of fruit juice do you drink a day? 0
1 2 3 4 5
How many glasses of water do you drink a day?
1 2 3 4 5
October 2013

How many cups of tea or coffee do you drink per day?
October 2013
1 2 3 4 5

How many times a week do you eat

fish?
red meat?
wholemeal grains high fibre cereals?
(including brown rice, whole wheat pasta, muesli, shredded wheat, etc.)
cheese?
eggs?
"healthy bacteria" (probiotics)?
convenience food?
Do you make efforts to cut salt in your diet? Yes No

Do you take any vitamin/mineral supplements? No Yes If yes, please write which ones and from
when: _______________________________________________________________________
Coffee: how many cups of coffee do you drink a day on average?
Do you know that 2 to 5 cups of coffee a day is good for cardiovascular health? Drinking more than
that is not beneficial.
Is there anything else you would like to tell us about your diet/nutrition? No Yes If yes,
please state details_____________________________________________________________
____________________________________________________________________________
You can find advice on diet/nutrition for health in our website at the Section
2 One portion of fruit corresponds to one apple or banana or pear or two slices of pineapple or a small bowl of fruits.
3. One portion of vegetables corresponds to two tablespoons of vegetables or one dessert bowl full of salad.
F.5 Sleep
Do you have sleep problems? No Yes If yes, please state details________________________
____________________________________________________________________________
Do you snore during sleep? (ask your partner if you snore)
Do people tell you that you snore?
Has anyone ever told you that you gasp for breath when you sleep?
No
No
No
Yes
Yes
Yes
(Do you know that we have a symbiotic relationship with a sleep clinic in the same building? If you are interested, ask for
details or visit sleeprhythmstresscentre.com or bocsleepcentre.com)
F.6 Stress
October 2013
Health MOT Detecting medical problems sooner

to improve health and longevity

Do you consider yourself under stress at present? No Yes If yes, please give reasons for your
stress: ______________________________________________________________________
Have you:
Lost much sleep through worry?
No Yes
Lost interest in activities you once enjoyed?
No Yes
Found it difficult to concentrate or make decisions? No Yes

Experienced restlessness or decreased activity?
No Yes
Felt constantly under strain?
No Yes
Lost your sex drive?
No Yes
(Do you need advice on how to improve your sex life? Please tick here.
We can arrange an appointment with doctor who
has a special interest in sex medicine.)
If you answered yes to more than two of the above questions, you may wish to check if you are mildly
depressed or just feeling a bit down. Please fill the next Section: Becks. Depression Inventory.
If you do not feel comfortable in filling it, please tick here
Depression (and anxiety)
Questionnaire is optional, although we strongly recommend it, because by filling it, you may score up
yourself and if you wish to see a specialist psychiatrist to discuss your situation in details, please feel
free to ask more information. Just tick here
Would you like hypnotherapy by our hypnotherapist? Please ask.
Please visit our website at the Section for more info about stress and health
F.7 Depression
Beck Depression Baseline Inventory
This questionnaire consists of 21 groups of statements. Please read each group of statements
carefully, and then pick out the statement in each group that best describes the way you have been
feeling during the past two weeks, including today. Circle the number beside the statement you have
picked. If several statements in the group seem to apply equally well, circle the highest number for
that group. Be sure that you do not choose more than one statement for any group, including Item
16(Changes in Sleeping Pattern) or Item 18 (Changes in Appetite).
Name:_________________________________________Marital Status: _________________
Age: ______Sex: ________ Occupation: ___________________________________________
Education: __________________________________________________________________
October 2013

1. Sadness
00
I do not feel sad.
5. Guilty Feelings
I dont feel particularly guilty.

I feel guilty over many things I have done or should have done.
I feel quite guilty most of the time.
I feel guilty all of the time.
1 I feel sad much of the time.

22
I am sad all the time.

34
34
I am so sad or unhappy that I can't stand it.
2. Pessimism
00
I am not discouraged about my future.
6. Punishment Feelings
112
I feel more discouraged about my future than I used to be.
223
I do not expect things to work out for me.
334
I feel my future is hopeless and will only get worse.
3. Past Failure
001
I do not feel like a failure.
7. Self-Dislike
I feel the same about myself as ever.

I have lost condence in myself.
I am disappointed in myself.
I dislike myself.
1
12
I have failed more than I should have.

As I look back, I see a lot of failures.
3
I feel I am a total failure as a person.
2
23
4. Loss of Pleasure
001
I get as much pleasure as I ever did from the things I enjoy.
1 I dont enjoy things as much as I used to.
2
23
I don't feel I am being punished.

I feel I may be punished.
I expect to be punished.
I feel I am being punished.
I get very little pleasure from the things I used to enjoy.

I cant get any pleasure from the things I used to enjoy.
8. Self-Criticalness
I dont criticize or blame myself more than usual.

I am more critical of myself than I used to be.
I criticize myself for all of my faults.
I blame myself for everything bad that happens.
Subtotal Page1
9. Suicidal Thoughts or Wishes

01
I dont have any thoughts of killing myself.
16. Changes in Sleeping Pattern
I have not experienced any change in my sleeping pattern.
1
1a I have thoughts of killing myself, but I would not carry them out.
23
I would like to kill myself.
1b
34
I would kill myself if I had the chance.
2a
2b
3a
3b
10. Crying
0
01
I don't cry more than I used to.
17. Irritability
I am no more irritable than usual.

I am more irritable than usual.
I am much more irritable than usual.
I am irritable all the time.
I cry more than I used to.

I cry over every little.
3
I feel like crying, but I cant.
2
11. Agitation
0
I am no more restless or wound up than usual.
12
1a
I feel more restless or wound up than usual.
2
I am so restless or agitated that it's hard to stay still.
3
I am so restless or agitated that I have to keep moving or doing
2a
something.
2b
October 2013
I sleep somewhat more than usual.

I sleep somewhat less than usual.
I sleep a lot more than usual.
I sleep a lot less than usual.
I sleep most of the day.
I wake up 1-2 hours early and can't get back to sleep.
18. Changes in Appetite
I have not experienced any change in my appetite.

My appetite is somewhat less than usual.
1b
My appetite is somewhat greater than usual.
My appetite is much less than before.
My appetite is much greater than usual.
10

3a
I have no appetite at all.

I crave food all the time.
3b
12. Loss of Interest

10
I have not lost interest in other people or activities.
19. Concentration Difficulty
23
I am less interested in other people or things than before.

I have lost most of my interest in other people or things.
34
It's hard to get interested in anything.
I can concentrate as well as ever.

I cant concentrate as well as usual.
Its hard to keep my mind on anything for very long.
I nd I can't concentrate on anything.
13. Indecisiveness
10 19. Concentration
I make decisions about as well as ever.
20. Tiredness or Fatigue

19. I am no
Concentration
more tired or fatigued than usual.
212
I nd it more difficult to make decisions than usual.
323
I have much greater difficulty in making decisions than I used to.
4
3 I have trouble making any decisions.
I get more tired or fatigued more easily than usual.

I am too tired or fatigued to do a lot of the things I used to do.
I am too tired or fatigued to do most of the things I used to do.
14. Worthlessness
101
I do not feel I am worthless.
12
I don't consider myself as worthwhile and useful as I used to.
3
23
I feel more worthless as compared to other people.
34
I feel utterly worthless.
21. Loss 0f Interest in Sex
2
12
15. Loss of Energy

1
I have as much energy as ever.
2
I have less energy than l used to have.
3
I don't have enough energy to do very much.
4
I don't have enough energy to do anything.
October 2013
I have not noticed any recent change in my interest in sex.

I am less interested in sex than I used to be.
I am much less interested in sex now.
I have lost interest in sex completely.
Subtotal Page 1 _______________
Subtotal Page 2 _______________
Total score 1+2 = ______________
11

G. DAYTIME SLEEPNESS AND EXCESSIVE TIREDNESS QUESTIONAIRE.

These could be due to allergies; Allergic tension fatigue syndrome, environmental allergy or effects
of toxins and fumes. Carbon monoxide poisoning presents this way.
Some people feel extremely tired or nodd off after a good night sleep.
Do you sleep well at night? Yes No
If you sleep well:
1) Do you feel sleepy during day time? No Yes
2) Do you feel excessively tired during day time? No Yes
3) Do you nodd off while driving or similar activity? No Yes
4) Do you nodd off in public transport? No Yes
5) Do you nodd off at work? No Yes
6) Do you yawn during day time? No Yes
If you answered NO at all the 6 questions above, please go to next section.
If you answered YES to any of the questions, please continue to fill the next section, which will help
to detect sleep disorders.
Please think about environment at home and work: Do you have any idea of any triggers in the
environment?
No Yes; if yes, please state _______________________________________
Please explore the environmental allergy yourselves and let us know.
H. ALTERNATIVE AND COMPLEMENTARY MEDICINE USAGE

H.1 Do you take any HERBAL medicine now? No Yes If yes, please state what and why you take
____________________________________________________________________________
____________________________________________________________________________
H.2 Do you take any OVER THE COUNTER medicine now?No YesIf yes, please state what and why
you take ____________________________________________________________________
____________________________________________________________________________
H.3 Do you take any NUTRITIONAL SUPPLEMENTS now?No YesIf yes, please state what and why
you take _____________________________________________________________________
____________________________________________________________________________
November 2013
12
Health MOT Detecting medical problems sooner

to improve health and longevity

H.4Do you take any BIOLOGICS(prescribed by doctor or over the counter) now?No YesIf yes,
please state what and why you take_________________________________________________
H.5Do you take any good bacteria yogurt (also called probiotics) now? No Yes
If yes, please state what and why you take____________________________________________
____________________________________________________________________________
H.6 Did you ever have acupuncture in the past? No Yes If yes, for what reason?
____________________________________________________________________________
H.7 ALLERGY
ALLERGY QUESTIONNAIRE
Allergy history questionnaire for adults, children and young person under 16 years old.
If you have an allergy to any food, medicine, peanut, bee sting etc., please tick here
Or tick here if no allergy known

If you think you may have allergy, please fill this questionnaire and think about your allergy. Think
about foods, drinks, additives, chemicals in perfumes, soaps etc. Think about the environment (at
home, school, work placed, friends place etc.).
You might like to keep a Food, Mood and Symptoms diary. If you have such diaries please bring them.
Why not to do a Food, Mood and symptoms diary from today. Note the environment too.
(To be completed by mother if patient is a child).
If possible you may like to ask your mother about your allergy history in infancy and childhood.
Allergy can begin in the womb because foetus is predisposed to atopy as a genetic condition. From
this questionnaire finding we will get your allergy history score. The higher the score, more the
chances of you having atopy/ allergic conditions.
A. In the womb-in utero.
.
No Yes
Did you notice extreme quietness of your baby in the womb?
No Yes
A.1 Was the baby overactive in the womb?

A.2 Similarly some babies are very quiet in the womb.
A.3 Babies can get hiccoughs in the womb when mothers can notice your baby having them.
No Yes
Did you notice hiccoughs?

If yes, do you know which food triggers the hiccoughs?
Please write________________________________________________________________
October 2013
13

A.4 Babies are sometimes tensed up in the womb as a result of allergy to the food mother took.
No Yes
Was the baby stiff at birth? Did mother notice this?
A.5 Some babies are floppy at birth due to allergy in the womb. Was your baby floppy?
No Yes
Did mother notice this in the first few days?
_________________________________________________________________________
B. Condition of skin at birth:

B.6. Eczema or very dry skin can be present at birth or in the first week of life.
Did mother notice? - Eczema ; Dry skin
Cracked skin at birth or soon after;
if yes, when was this first noticed? ______________ age in months.
C. Feeding:
C.7 Babies with allergy are generally speaking poor feeders. Did mother notice this?
No Yes
C.8 They vomit or posset a lot. Did mother notice excessive vomiting or posseting?
No Yes
C.9 Get colic a lot. Did mother notice the baby cry a lot due to colic?
No Yes
C.10 Needed colic medication for over 1 month. Did mother give colic medication?
No Yes
If yes, what medication__________________________________________________________
D. Behaviour:
D.11 Allergic tension-irritable and very alert most of the time in the first year.
No Yes
D.12 Allergic tension-fatigue syndrome. Was the baby tenced or irritable a lot of the time? Like
Jackle and Hyde personality? At one time tensed and irritable and other time sleepy and quite?
No Yes
E. Multisystem disorder:
Allergy is a multisystem disorder meaning it can affect various systems and organ: lungs, gut, kidney,
skin, brain etc. please stage at what age in months or years these were noted.
Please tick if you ever had (or still have):
Age of first noticed
E.13 Severe nappy rash
No Yes
_______________
E14. Urticarial Pruritus (severe itchy skin)
No Yes
_______________
E15. Eczema
No Yes
_______________
October 2013
14

E16. Angio oedema
No Yes
_______________
E17. Laryngeal oedema
No Yes
_______________
E18. Hypotension
No Yes
_______________
E19. Anaphylaxis
No Yes
_______________
E20. Asthma
No Yes
_______________
E21. Rhinitis (runny nose)
No Yes
_______________
E22. Abdominal pain/colic
No Yes
_______________
E23. Bloating of stomach, passing excessing wind (foul smelling)
No Yes
_______________
E24. Diarrhoea
No Yes
_______________
E25. Reflux
No Yes
_______________
E26. Colitis with blood stool (proctitis)
No Yes
_______________
E27. Food aversion
No Yes
_______________
E28.Hiccups
No Yes
_______________
E29. Eye twitching
No Yes
_______________
E30. Constipation
No Yes
_______________
E31. Straining to pass stools
No Yes
_______________
E32. Irritable bowel syndrome
No Yes
_______________
E33. Excessive eating (abnormal satiety)
No Yes
_______________
E34. History of pyloric stenosis
No Yes
_______________
E35. Otitis media (glue-ear)
No Yes
_______________
E36. Irritability
No Yes
_______________
E37. Tension and fatigue syndrome
No Yes
_______________
E38. ADHD
No Yes
_______________
E39. Migraine
No Yes
_______________
E40. Epilepsy
No Yes
_______________
E41. Brain allergy mood swing
No Yes
_______________
October 2013
15

E42. Cramps
No Yes
_______________
E43. Poor sleep
No Yes
_______________
E44. Joint pains
No Yes
_______________
E45. Faecal incontinence
No Yes
_______________
E46. Bedwetting
No Yes
_______________
E47. Severe unexplained loin pain (loin pain haematuria syndrome)
No Yes
_______________
E48. Fast heart rate (increased frequency)
No Yes
_______________
E49.Fibromyalgia
No Yes
_______________
E50. Passing urine several times in the day
No Yes
_______________
E51. Neil deformity (ridging, braking, thinning of nail oncholysis)
No Yes
_______________
E52. Vaginal discharge (without infection)
No Yes
_______________
E.53 Fertility problem (being slow to conceive) or infertility
No Yes
_______________
E.54 Early menopause
No Yes
_______________
E.55 Early andropause (erectile dysfunction in men)
No Yes
_______________
E.56 Night sweat
No Yes
_______________
E.57 Joint hypermobility
No Yes
_______________
E.58 Breast smelling
No Yes
_______________
E.59 Mouth ulcers
No Yes
_______________
F.60 Ataxia (balance difficulties)
No Yes
_______________
F.61 Headache
No Yes
_______________
F.62 Sensory disturbance
No Yes
_______________
F.63 Muscle pain
No Yes
_______________
F.64 Epilepsy
No Yes
_______________
F.65 Myoclonic attack (hyperexcitable brain)
No Yes
_______________
F. Triggers:
October 2013
16

F66. Double chin
No Yes
_______________
F.67 Thunder thighs
No Yes
_______________
F.68 Muffin top
No Yes
_______________
F.69 Back fat
No Yes
_______________
F.70 Thick ankles
No Yes
_______________
F.71 Abnormal CT scan
No Yes
_______________
F.60 Do you know what brings on you symptoms?
No Yes
If yes, what? Please state: ____________________________________________
Do you consider that you might have coeliac disease? No Yes;

or Lactose intolerance? No Yes
if yes, have you had any test for coeliac disease? No Yes; if no, do you like us to test for you?
No Yes: similarly have you had test for Lactose intolerance? No Yes (this will be breth
test after taking 50g lactose in to the laboratory).
Please list the triggers: foods, inhalants, contact substances etc. If you like to have blood test (IgE
antibodies by RAST) on or Skin Prick Test we will take note of your requirement. Always discuss with
the nurse (or doctor if you are seeing a doctor) to decide the best test for you.
F.61 Have you observed symptoms improvement when you cut or remove the trigger substance?
No Yes
When did you first have cows milk as Formula milk? _______________________________
When you first had Formula milk, did you as a baby develop any symptoms?
No Yes
When did you start have door step cows milk? ______________________________________
When did you first take wheat (gluten) containing foods? _________________________________
Did wheat (gluten) upset you as baby in any way when it was first introduced? No Yes
If you have wheat intolerance now, tick here
and please state how it affects you.
G. Questions on Lactose intolerance.

I had a bad smell, vomiting everyday for eleven days, some days after every meal. This was said by Charles Darwin who had
Lactose intolerance.
No Yes
G.62 Gout pain (abdomen)
October 2013
17

No Yes
G.63 Loin pain

G.64 Bloating
No Yes
G65. Constipation
No Yes
G.66 Diarrhoea
No Yes
G.67 Flatulence
No Yes
G.68 Headache
No Yes
G.69 Nausea
No Yes
G.70 Vomiting
No Yes
G.71 Light headedness
No Yes
G.72 Concentration loss
No Yes
G.73 Muscle pain
No Yes
G.74 Joint pain
No Yes
G.75 Severe fatigue
No Yes
G.76 Palpitation
No Yes
G.77 Fast heart rate
No Yes
G.78 Sinus problem
No Yes
G.79 Drunk feeling
No Yes
G.80 Stiff neck
No Yes
H. Family history:
H.81 Is there a family history of allergy?
No Yes
H.82 Is there a family history of coeliac disease?
No Yes
H.83 Who is allergic in the family? Please, state name and relationship _______________________
H.84 Was it food allergy?
No Yes
H.85 Was it inhalant allergy?
No Yes
H.86 Do you have anyone in your family who had peanut allergy?
No Yes
H.87 Do you know anyone in your family who had anaphylaxis?
No Yes
October 2013
18

H.88 Is there anything else you want to tell us about your allergy?
No Yes
if yes to any questions please give details ________________________________________
1. Asthma and Rhinitis

There are atopic conditions, often trigged by allergies to food or environmental substances.
These include house dust mite, pollens, moulds etc. Skin prick test can help to identify the
triggers.
1.1 Asthma and Chest Infections
1.1.1Does anyone close in your family have (had) rhinitis or asthma?
1.1.2Did you have asthma ever? No YesIf yes, please state details___________________________
1.1.3Did you have a lot of chest infections? No Yes If yes, please state details _______________
___________________________________________________________________________________
1.2 Smoking (Smoking is the biggest risk factor for developing asthma and COPD)
Do you smoke, now? No Yes If yes, please state details __________________________________
___________________________________________________________________________________
Did you smoke ever? No Yes If yes, please state details _________________________________
How many years did you smoke in total ________________
How many cigarettes per day on average did you smoke? (smoking is not only cause of lung cancer, it triggers
asthma and is an important cause for COPD and myocardial infarct-heart attack.)
2. ASTHMA AND COPD SYMPTOMS

2.1 Cough
2.1.1 Do you have cough in the night? No Yes If yes, please state details
__________________________________________________________________________________
2.1.2 Do you have cough first thing in the morning? No Yes If yes, please state details
__________________________________________________________________________________
2.1.3 Do you bring up sputum? No Yes If yes, please state details

___________________________________________________________________________________
2.1.4 Do you wheeze? No Yes If yes, please state details

__________________________________________________________________________________
2.2 Shortness of breath

2.2.1 Do you get short of breath when walking (while others walk easily)? No Yes
October 2013
19

2.2.3 Do you get short of breath when you climb up a few steps (while others climb them without any
difficulties)? No Yes
3. TESTS
3.1 Lung Function Test Spirometry (please discuss with the nurse)
3.1.1 Have you ever had Spirometry or Peak flow Assessment? Yes No If yes, what was your
best peak flow? ____________
If you never had a peak flow measurement and like to have one now, please tick this box
. You will need to
pay 5.
J. BODY FAT
Carrying excessive fat is not healthy. Fat cells produce inflammation which affects the heart and
arteries. Excessive body fat triggers diabetes. Fat cells are inflammatory cells. They can trigger
provoke allergies.
J.1 Do you think you are overweight? No Yes If yes, what actions are you taking to reduce your
body weight? _________________________________________________________________
____________________________________________________________________________
J.2 Do you wish to have your body fat analysis carried out today? Yes No.
You need to pay 5 for body fat analysis.
Note: 1. In our clinic we provide a fat reduction treatment through CRYO-LIPO THERAPY, using an
innovative and non-invasive FDA approved technology. This is by freezing cells to death. We believe
that it delivers results far better than any other lipo therapy. This FDA approved therapy developed
in USA can destroy 26% of fat in just one session at each treatment area of treatment. We may be
able to treat two treatment areas in one day giving you two treatments over nearly two hours in one
day. You pay 99 for one area of treatment instead of 500.
If you are interested in getting more information about how Cryo Lipo therapy works, please tick
here
A member of our team will be happy to help you.
2. We have a Weight and Wellness Clinic run by an experienced doctor interested in weight
management. Do you wish to attend this clinic? No Yes.
October 2013
20

This clinic is run by an experienced doctor working in this area of medicine. The doctor will assess you
and will suggest treatment option with you. You can arrange to attend this clinic you pay 79
instead of350 for your assessment.
ACUPUNCTURE
Acupuncture can help fight allergies. It can help to boost immunity. Reduce pain.
1. Have you ever had acupuncture? No Yes If yes, why and when?
____________________________________________________________________________
2. Would you consider acupuncture as a treatment modality? No Yes If yes, please note we have
a doctor who can do acupuncture Medical acupuncture. At Medical Express Clinic acupuncture is
carried out by a doctor registered with GMC.
Fertility and sex and sexuality: Love MOT
It is (just) possible that your fertility might be affected as a result of food allergy. Here, we are
asking you to think about this matter and your sexual satisfaction; orgasm, erectile dysfunction,
premature ejaculation.
If you wish NOT to answer these questions, please tick here ,
none of the above applies to me
and leave this section blank.
K. PATIENT CHOICE
It is important that your GP is fully aware of all your health needs and findings from our clinic.
Therefore we are asking an authorization to you in order to send a copy of the report to your GP.
Alternatively you may prefer taking a copy of the report with you and give it personally to your GP.
We will not be sending a copy of this report to anyone unless you instruct us to do so.
Please let us know your choice by ticking one of the following boxes:
A. I request Medical Express Clinic to send a copy of my report to my GP; details are given below
B. I will take a copy of the report and give it personally to my GP.

For this reason I am not giving my GPs details
C. I wish my GP NOT to know about the present health MOT.

For this reason I am not going to give my GPs details
October 2013
21

GPs name (where your report will be sent):

________________________________________________
Address: ____________________________________________________________________
______________________________________________ Postcode: _____________________
If you are under a consultant/specialist state details if you wish us to send a copy of the report
Name of specialist: _____________________________________________________________
Address: ____________________________________________________________________
______________________________________________ Postcode: _____________________
Do you wish us to send a copy of the report to your specialist? Yes No
1.This is Section A: Health and Lifestyle Questionnaire with Allergy Questionnaire. Please fill section
B: Medical Express Clinic Medical Questions: Your Health (attached to this questionnaire).
2. If you are attending for Allergy testing and you are having Skin-Prick-Test, please think in
advance what allergens you would like to have the Skin Prick Test carried out with. You are
welcome to bring your own allergens.
You will have standard two prick tests. Everyone will have this.
a) Histamine as positive control
b) Saline as negative control
You can write down up 8 more allergens you wish to have tested (a total of 10 tests).
Please see the list of allergens we have. Now we have 50 allergens which we have imported for use
at the clinic.
Please bring any allergen (fruit, milk-including fresh milk, breast milk or other milks you are using,
soya protein, soya milk, cheese of your choice, meat of your choice, fish, prawn, vegetable, flour etc.
We may have wheat as a commercially produced antigen. Please ask.
We will try and assist by doing Prick to Prick test with the allergens you choose.
If you want us to do more than 10 (maximum 15 Tests), than you need to pay 10 per each prick test
over 10.
Note: we have imported 50 new antigens to give you a variety. These are expensive new addition. You
still pay 10 for each new antigen you want us to do skin test with. You may select up to 6 in one
session, giving a total of 16 prick tests in one session. You pay for any test done above 10. Use the
test form to tick the ones you want us to do. You may book another day next week and do 10 more if
you prefer.
Thank you for filling these forms.
We are ready to listen to you.

We are ready to assist.
October 2013
22

We will try and answer your questions.

We will try and meet your expectations.
Please note that we can do lot more tests; measure your vitamin levels, check your blood for anaemia,
iron deficiency, thyroid problems, and kidney and liver function abnormalities.
We can check you for diabetes or prediabetis.
Our usual price for such tests is 80+35=115
You pay 49 and have it done today. If you add Vitamin D to above you pay 79.
Ask the nurse at reception and have the blood test today at this bargain price.
We can do Lactase intolerance test by breath tests.
We can do IgE mediated specific antibodies in blood and now IgG mediated specific test. Please read
about these tests. Ask us if you wish to have these done.
We have test for coeliac disease blood test.
October 2013
23


Allergy Test Part A

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MEDICAL EXPRESS CLINIC

and Allergy Evaluation.

Mrs Dr Professor Sir Madam

Date of Birth: _________________

Country of Birth: _____________________

Address (where your report will be sent): __________________________________________

__________________________________ Postcode: _____________________________

Are you now Student

Looking for work

If not working have you ever worked? Yes

If yes, please continue with the next questions.

If no, please go to Section C. (medical history)

If no, what was your last job? ____________________

Your occupation: ___________________

If yes, please state: ____________________________________________________________

Health MOT Promoting longevity

Copyright: Professor Sam Lingam

If yes, please state details: ______________________________________________________

No, please fill the Allergy Questionnaire, later in this Questionnaire.

If yes, please state: ____________________________________________________________

Yes If yes, please state details:

If yes, please state details:____________________________

7. Have you ever had a mental health problem? No Yes

Some mental health problems (including

Anxiety Disorder Panic attack

or other, please state: __________________________________________________________

Health MOT- Helping to remain young longer

Copyright: Professor Sam Lingam

Please indicate your personal relationship status at the present time:

Long Term Relationship Divorced/Separated Widowed Cohabiting

Lesbian Other, state:______________________

Is your partner in good health? Yes

Do you consider that you are in a stable relationship? Yes

Yes If yes, state________

If yes, write in your children's ages if applicable.

Do your children have any significant medical or educational problems? No

Health MOT- Helping to remain young longer

Copyright: Professor Sam Lingam

Women only answer the following questions.

If yes, state: _____

If yes, state: ____________________

Are your period regular? No

if yes, at what age? ____________

if not, what is the problem? ___________________

Other If other, please give details_________________________

If yes, state: ____

Health MOT- Helping to remain young longer

Copyright: Professor Sam Lingam

please go to the last two questions marked *

I used to smoke, but I stopped

Yes, I smoke I started to smoke at

If you smoke, how many cigarettes/cigars/ pipe do you smoke at present?

cigars per day

pipe per day

If yes, when was your last chest x-ray? ___________________________________________

Would you like to quit smoking? Yes

Would you like to have hypnosis or acupuncture

Discuss with the doctor.

treatment at our clinic privately?

* If you do not smoke, are you a regular passive smoker? No

please go to the last two questions marked *

I used to drink alcohol, but I stopped

If you are a drinker, what do you usually drink? Beer

______ Postcode: _