This form is ONLY for patients of JURA Health who currently have no prescribing Doctor, but have been initiated on therapy or had their initial consultation. This is a brief consultation with a prescriber who will attempt to safely continue your treatment pathway, but this is not an in depth conversation or consultation. This is due to the current emergency situation caused by services being dropped by Jura Health. Do not fill in this form if you are a new patient who has not already been assessed, as we will not be able to proceed. 

Full consultation and follow up will occur once we have cleared the current backlog of urgent patient need caused by this unprecedented situation.

Please enable JavaScript in your browser to complete this form.

– Step 1 of 8

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

NextSave and Resume Later

Section 2

Medical History

Have you been diagnosed with Mast Cell Activaton Syndrome or POTS *

• 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? *

NextSave and Resume Later

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
• Rapid heartbeat when standing
• Dizziness or feeling faint on standing
• Severe fatigue
• Palpitations
• Shortness of breath or chest discomfort
• Nausea or digestive upset
• Cold or discoloured hands and feet
• None of this applies to me as I’m well controlled on my current medicines

Rapid heartbeat when standing Dizziness or feeling faint on standing Severe fatigue Brain fog or difficulty concentrating Palpitations Shortness of breath or chest discomfort Nausea or digestive upset Cold or discoloured hands and feet

Any other symptoms

NextSave and Resume Later

Section 4: Triggers

I feel that I am triggered by the following things

• Foods
• Temperature changes
• Exercise
• Stress
• Environmental factors (pollen, mould, chemicals)
• Fatigue
• Medications / supplements
• None of these – I’m well controlled on my current medicines

I know I am specifically triggered by:

NextSave and Resume Later

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? *

NextSave and Resume Later

Section 6: Safety & Suitability

Do you have a history of severe allergic reactions (anaphylaxis)? *— Select Choice —YesNo

Do you carry an adrenaline auto-injector (e.g. EpiPen)? *— Select Choice —YesNo

Are you pregnant or breastfeeding? (Yes/No/Not applicable) *— Select Choice —YesNoNot applicable

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

Any other safety concerns we should know about? *

NextSave and Resume Later

Section 7: Lifestyle & Quality of Life

Please describe how MCAS or POTS 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)

NextSave and Resume Later

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

SubmitSave and Resume Later