Shingles Treatment in Hackney, London | NHS Pharmacy First Service

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DO YOU HAVE ANY OF THESE SYMPTOMS?

Neck stiffness, sensitivity to light, mottled skin (meningitis)
YES NO

PLEASE REFER TO THE PHARMACIST FOR ONWARD REFERRAL TO AN APPROPRIATE HEALTHCARE PROVIDER. YOU DO NOT NEED TO COMPLETE ANY MORE DETAILS ON THIS FORM IF YES TO ANY OF THE ABOVE

Disorientation, changes in behaviour (encephalitis)
YES NO

PLEASE REFER TO THE PHARMACIST FOR ONWARD REFERRAL TO AN APPROPRIATE HEALTHCARE PROVIDER. YOU DO NOT NEED TO COMPLETE ANY MORE DETAILS ON THIS FORM IF YES TO ANY OF THE ABOVE

Muscle weakness, loss of bladder / bowel control (myelitis)
YES NO

PLEASE REFER TO THE PHARMACIST FOR ONWARD REFERRAL TO AN APPROPRIATE HEALTHCARE PROVIDER. YOU DO NOT NEED TO COMPLETE ANY MORE DETAILS ON THIS FORM IF YES TO ANY OF THE ABOVE

Facial nerve paralysis (possible on one side – Ramsay Hunt)
YES NO

PLEASE REFER TO THE PHARMACIST FOR ONWARD REFERRAL TO AN APPROPRIATE HEALTHCARE PROVIDER. YOU DO NOT NEED TO COMPLETE ANY MORE DETAILS ON THIS FORM IF YES TO ANY OF THE ABOVE

Shingles in the facial region – rash on the tip, side or root of the nose, visual symptoms, unexplained red eye
YES NO

PLEASE REFER TO THE PHARMACIST FOR ONWARD REFERRAL TO AN APPROPRIATE HEALTHCARE PROVIDER. YOU DO NOT NEED TO COMPLETE ANY MORE DETAILS ON THIS FORM IF YES TO ANY OF THE ABOVE

Severely immunosuppressed / widespread rash / systemically unwell (e.g. fever)
YES NO

PLEASE REFER TO THE PHARMACIST FOR ONWARD REFERRAL TO AN APPROPRIATE HEALTHCARE PROVIDER. YOU DO NOT NEED TO COMPLETE ANY MORE DETAILS ON THIS FORM IF YES TO ANY OF THE ABOVE

HAVE YOUR SYMPTOMS FOLLOWED THIS PROGRESSION?

Abnormal skin sensation and pain in the affected area which can be described as burning, stabbing, throbbing, itching, tingling which can be intermittent or constant
YES NO

Rash developed 2 – 3 days after the onset of pain and or a fever and or a headache
YES NO

Rash appears as a group of red spots on a pink-red background which quickly turns into small fluid-filled blisters
YES NO

Burst blisters / filled with blood or pus which slowly dries, crusts and scabs forms
YES NO

Rash covers a well-defined area of the skin on one side of the body only and does not cross to the other side of the body
YES NO

PATIENT DETAILS

First Name:

Last Name:

Email:

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DOB:

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GP Practice:

MEDICAL HISTORY

Within 72 hours of rash onset
YES NO

Up to one week after rash onset
YES NO

Longer than one week after rash onset
YES NO

IF LONGER THAN ONE WEEK – SELF CARE ADVICE AND SAFETY NETTING
DO ANY OF THE FOLLOW APPLY TO YOU

Are you immunosuppressed
YES NO

Is the shingles affecting the neck, limbs or anal region (not the trunk)
YES NO

Moderate or severe pain
YES NO

Moderate or severe rash
YES NO

Continued blister formation
YES NO

High risk of severe shingles forming (e.g. severe atopic dermatitis / eczema)
YES NO

MEDICAL HISTORY

Do you take any medication (please list)
YES NO

Do you have any allergies?
YES NO

Shingles Adults aged 18 years and over (excluding pregnant individuals)

DO YOU HAVE ANY OF THESE SYMPTOMS?

HAVE YOUR SYMPTOMS FOLLOWED THIS PROGRESSION?

PATIENT DETAILS

MEDICAL HISTORY

IF LONGER THAN ONE WEEK – SELF CARE ADVICE AND SAFETY NETTING
DO ANY OF THE FOLLOW APPLY TO YOU

MEDICAL HISTORY

DO YOU HAVE ANY OF THE SYMPTOMS BELOW? IF YES, PHARMACIST TO UNDERTAKE A NEWS2 SCORE

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Shingles Adults aged 18 years and over (excluding pregnant individuals)

DO YOU HAVE ANY OF THESE SYMPTOMS?

HAVE YOUR SYMPTOMS FOLLOWED THIS PROGRESSION?

PATIENT DETAILS

MEDICAL HISTORY

IF LONGER THAN ONE WEEK – SELF CARE ADVICE AND SAFETY NETTINGDO ANY OF THE FOLLOW APPLY TO YOU

MEDICAL HISTORY

DO YOU HAVE ANY OF THE SYMPTOMS BELOW? IF YES, PHARMACIST TO UNDERTAKE A NEWS2 SCORE

USUAL OPENING HOURS

IF LONGER THAN ONE WEEK – SELF CARE ADVICE AND SAFETY NETTING
DO ANY OF THE FOLLOW APPLY TO YOU