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Online Allergy Test

Please complete all sections of the questionnaire and submit your form once done.

Step 1 of 2

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First Name*
Last Name*
Gender*
- Male
- Female
Date of Birth*
DD slash MM slash YYYY
Email*
Enter Email Confirm Email
Phone*
Why do you want to do the 112 components allergy test? What is the main problem with your health?*
Address for delivery of your test kit*
Address City Post code Country
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Section 1 - About You
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Occupation
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Brief description of workplace environment
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Do you suffer from any long term medical conditions?
- Yes
- No
If yes, please give details
If yes, please give details
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Please list any medication you take, including supplements, topical applications (creams etc) and over the counter medication:
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Section 2 - Your Environment
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Do you live in a house or a flat?
- Flat
- House
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What area do you live in?
- Country
- Suburb
- City
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Are any areas of the property damp?
- No
- Yes
- Basement
- Bathroom
- Attic
- Other
If Yes, please give details (where, when, any mould stains?)
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Section 3 - Pets
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Do you have any pets at home?
- Yes
- No
If yes, please give details (E.g. long haired dog)
How long have you had the pet(s)?
Does the pet have full run of the house?
- Yes
- No
Does the animal sleep on your bed?
- Yes
- No
Does exposure make the symptoms worse?
- Yes
- No
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Section 4 - Your allergies and symptoms
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Are you allergic to any drugs?
- Yes
- No
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What are the problems that you are having?
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Please give details:
Please give details:
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Do you have a latex allergy?
- Yes
- No
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Ear Problems
- Yes
- No
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What symptoms do you get and how long do they last?
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Nasal Problems
- Yes
- No
What symptoms do you get and how long do they last?
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Chest/Breathing Problems
- Yes
- No
What symptoms do you get and how long do they last?
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Throat Problems
- Yes
- No
What symptoms do you get and how long do they last?
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Eye Problems
- Yes
- No
What symptoms do you get and how long do they last?
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Skin Problems
- Yes
- No
What symptoms do you get and how long do they last?
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Do you take any antihistamines regularly when you have symptoms?
- Yes
- No
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What symptoms do you get and how long do they last?
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Does the antihistamine help?
- Yes
- No
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Do the above symptoms occur at a particular time? (E.g. in April & May, during autumn, or in cold weather)
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Medications
- Yes
- No
- Don't know
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Perfume/Aftershave
- Yes
- No
- Don't know
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Heat/Cold
- Yes
- No
- Don't know
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Weather Changes
- Yes
- No
- Don't know
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Cigarette Smoke
- Yes
- No
- Don't know
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Humidity/Damp
- Yes
- No
- Don't know
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Air Conditioning
- Yes
- No
- Don't know
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Pollution
- Yes
- No
- Don't know
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Section 5 - Food Allergies
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Do you have any food allergies?
- Yes
- No
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Please give details of any food allergies/sensitivity and briefly describe the reaction. Please state if the reaction is immediate or delayed:
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If any, please give details of foods you avoid and why:
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Section 6 - Hay fever/Pollen allergy
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Do you suffer from Hay fever or Pollen allergies?
- Yes
- No
How old were you when your hay fever first started?
During which month(s) do you suffer with symptoms?
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
Do you have any problems eating fruit?
- Yes
- No
Do you ever get an itchy or swollen mouth with
- Apples
- Pears
- Peaches
- Plums
- Nectarines
- Cherries
- Other
Does this only happen with fresh fruit?
- Yes
- No
How much does this worry you?
- Not at all
- A little
- Moderately
- A lot
Swelling at site?
- Yes
- No
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Section 7 - Insect Allergy
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Have you ever had a reaction after an insect bite?
- Yes
- No
Do you suffer from any of the following, after a bee/wasp sting:
Hives at site
- Yes
- No
Details of where:
Shortness of breath
- Yes
- No
Swelling elsewhere
- Yes
- No
Hives elsewhere
- Yes
- No
Have you ever been treated in A & E for an insect sting?
- Yes
- No
If yes please give details:
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Section 8 - Asthma
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Do you suffer from Asthma?
- Yes
- No
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Have you ever been intubated, placed in intensive care, or on a respirator for asthma?
- Yes
- No
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How many times have you attended hospital because of your asthma?
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How many times have you visited your doctor because of your asthma?
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What is your best peak flow reading (leave blank for unknown)?
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How many times have you been prescribed oral steroids for your asthma in the past year?
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In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school, or at home?
- None of the time
- Once or twice a week
- Some of the time
- Most of the time
- All of the time
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During the past 4 weeks, how often have you had shortness of breath?
- More than once a day
- Once a day
- 3 to 6 times a week
- Once or twice a week
- Not at all
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During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?
- 4 or more nights a week
- 2 or 3 nights a week
- Once a week
- Once or twice
- Not at all
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During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication?
- 3 or more times a day
- 1 or 2 times a day
- 2 or 3 times a day
- Once a week or less
- Not at all
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How would you rate your asthma control during the past 4 weeks?
- Not controlled at all
- Poorly controlled
- Somewhat controlled
- Well controlled
- Completely controlled
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Other details
I am happy to receive the test results by email in encrypted form and give my consent for processing of my personal information in accordance with the privacy policy, available on the website. I give consent for the use of anonymised information from this questionnaire and test results for teaching, audit and research purposes. I agree with the refund policy. I understand that the fee does not include consultation.*
- Agreed
You are requesting component allergy test specific IgE self collection kit. (You don't need to change your diet, fast or stop your medication prior to this test) This test can be done from a finger prick or from a vein (sample can be taken by a nurse in our laboratory). Individual allergy tests are available in our Centre £34 per allergen (excluding the laboratory handling fee), more than 400 allergens are available please contact support if the allergen you would like to test is not present on the ISAC panel info@ukallergy.com. If you will want to discuss results or need medical help you can book an appointment with our consultants online. Although the testing is done in the accredited laboratory with appropriate quality controls in place, like all blood tests, there is a small possibility that the test will provide false positive results or false negative results. Please do not take any decisions or actions to change your medication or diet based on the results of the test without consulting your GP or allergy consultant first. Only a healthcare professional can diagnose and treat allergy.

I give permission for a copy of the results to be sent to my GP. This is a required field.
- Agreed
- Disagree
GP's Address if selecting Agreed from above
Street Address Address Line 2 City Country Post Code Country
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If you are after testing for one or two allergens or you would to have an appointment with the consultant first please email info@ukallergy.com and check with our team. If you have any further information to add. Please use the form below.
ISAC 112 components IgE allergy test*
Price:

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