MCASCLINICBOOKING – Dickson Chemist

Name

First

Last

Address:

Date of birth – please note you must be over 18. Minors must have a face to face consultation with a registered doctor or pediatrician – call us on 0141 404 6545 option 1 for a referral.

Email

Best phone number to get you on

Who is your primary care physician (GP) as we may need to talk to them about your request unless you opt out

I will contact my GP myself, you do not have my permission to contact my primary care providers about my care.

Tick here

I am not currently pregnant, and will take (if appropriate) precautions against this during therapy. (NOTE: Our prescribers are not insured to prescribe to assist with fertility problems.)

Tick here

I formally consent for Dickson Chemist to act on my behalf, to arrange a consultation.

Agree

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Section 2

Medical History

Have you been diagnosed with Mast Cell Activaton Syndrome

Yes
No
Not sure / it’s more complicated

If so, who and when

Please list any other medical conditions you have been diagnosed with

Please list any surgeries, hospital admissions, or major illnesses in the last 5 years

Family history of allergies, autoimmune disease, or mast cell-related conditions?

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Section 3: Current Symptoms

Please select all that apply to you

Flushing / hives / rashes
Swelling (angioedema)
Breathing difficulties / wheezing
Gastrointestinal symptoms (diarrhoea, bloating, abdominal pain)
Cardiovascular symptoms (palpitations, dizziness, low blood pressure)
Fatigue
Brain fog / concentration difficulties
Headaches / migraines

Any other symptoms

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Section 4: Triggers

I know I am specifically triggered by:

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Section 5: Previous & Current Treatments

Have you tried any treatments for your condition before?

Did you find any helpful?

Are you currently taking any regular medications or supplements?

Do you have any known drug, food, or environmental allergies?

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Section 6: Safety & Suitability

Do you have a history of severe allergic reactions (anaphylaxis)?

Do you carry an adrenaline auto-injector (e.g. EpiPen)?

Are you pregnant or breastfeeding? (Yes/No/Not applicable)

Do you have any diagnosed liver, kidney, or heart problems?

Any other safety concerns we should know about?

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Section 7: Lifestyle & Quality of Life

Please describe how MCAS symptoms affect your daily life

Dietary habits (any restrictions or special diets)

Alcohol, caffeine, or recreational drug use?

Sleep quality

Selected Value: 1

Please describe your sleep quality – higher is better

Stress levels

Selected Value: 1

Please describe your stress levels on an average day (lower is better)

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Medical evidence upload. 1) Evidence of diagnosis if you have it 2) Photographic ID or selfie holding a household bill 3) Evidence of any medications you take (such as a repeat form)

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Additional Comments / Tell us a little bit about yourself and any pertinent history we haven't specifically asked about