Gluten Intolerance Testing

First Name*

Last Name*

Gender

Male
Female

Date of Birth

Address*

Address Line 1 Address Line 2 City County Post code Country

Email*

Enter Email Confirm Email

Phone

Section 1 - About You

Occupation

Brief description of workplace environment

Please state number of days missed form work in the last year because of allergy symptoms

Do you Drink Alchohol?

Yes
No

If yes, how many units per week?

1 unit = ½ pint of beer, 1 spirit measure, ½ small glass of wine

Do you smoke?

Yes
No

If yes, how many cigarettes per day?

Do you suffer from any long term medical conditions?

Yes
No

If yes, please give details

Please list any medication you take, including supplements, topical applications (creams etc) and over the counter medication:

Have you ever had major surgery or been hospitalised?

Yes
No

Please give details and the date of admission:

Does/did anyone in your family (other than you), suffer from the following:

Asthma

Yes
No

Who?

Father
Mother
Siblings
Grandparents

Drug Allergies

Yes
No

Who?

Father
Mother
Siblings
Grandparents

Eczema

Yes
No

Who?

Father
Mother
Siblings
Grandparents

Hay Fever

Yes
No

Who?

Father
Mother
Siblings
Grandparents

Food Allergies

Yes
No

Who?

Father
Mother
Siblings
Grandparents

Please give details:

Section 2 - Medical

Do you get abdominal symptoms after drinking milk?*

Yes
No

What are the symptoms?

Bloating
Diarrhoea
Constipation
Rash
Swelling
Other

Do you get abdominal symptoms after having bread, pasta, beer?*

Yes
No

What are the symptoms?

Bloating
Diarrhoea
Constipation
Rash
Swelling
Other

Do you avoid eating gluten/wheat?*

Yes
No

When was the last time you ate gluten or wheat?

Section 3 - Other details

If you have any further information to add on any aspect of your condition, please do so below.

Section 4 - Consent

I give permission for a blood sample to be collected from a finger-prick or a vein, for the purpose of a specific IgE test. This is a required field.*

Agreed

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

I give consent for the use of anonymised information from this questionnaire and test results for teaching, audit and research purposes. This is a required field.*

Agreed

Payment and sample collection*

Price £393 You will receive a collection kit in the post to take a sample at home using video instructions (For childern under 5 years old or if you don't feel confident to collect the sample yourself you can bring the kit and the request form to our lab in central London (Oxford Circus) where a nurse will take a blood sample or make your own arrangements with a healthcare professional capable of taking the sample locally and post to our lab in prepaid envelope) I will send a labeled sample with the patient's name and date of birth

Section 1 - About You

Section 2 - Medical

Section 3 - Other details

Section 4 - Consent

Appointment lines:

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