Thank you for making your booking for your MCAS consultation.

Please now tell us everything you can and fill in the form below. NOTE: You will need a scan or photo of your photo identification or a picture of you holding a household bill and any paperwork showing a diagnosis plus evidence of what medicines you take (if any). Please gather this before starting.

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– 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

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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 feel that I am triggered by the following things

• Foods
• Temperature changes
• Exercise
• Stress
• Environmental factors (pollen, mould, chemicals)
• Fatigue
• Medications / supplements

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)? *— 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? *

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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

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