Care Search & Select Recruitment Referral Form

Care, Search & Select - Latex & Allergy Form

Name*
First Last
Date of Birth*
1. Do you have a history of any of the following?*
- Asthma - YES
- Asthma - No
- Hand Eczema - YES
- Hand Eczema - NO
- Hay Fever - YES
- Hay Fever - No
- Eczema anywhere else on your body - YES
- Eczema anywhere else on your body - No
Please select the condition and YES option if you have had any of the conditions below. If you haven't then select the condition and NO option.
2. Have you ever had surgery?*
- Yes
- No
If yes, then please give details
3. Have you had extensive dental work?*
- Yes
- No
4. Do you have any congenital abnormalities (e.g. spina bifida)?*
- Yes
- No
If yes, then please say the type
5. Do you have an allergy to any medicines, foods or other items?*
- Yes
- No
If yes then please state what
If you have answered yes to ANY of the questions this far then please continue to complete this form. If you have answered no to ALL of the questions this far, you may go the bottom of the form, sign date and submit it.
6. Have you ever reacted after handling or using the following items?
- Balloons
- Contraceptives
- Rubber Gloves
- Dental Blocks
- Hot water bottles
- Erasers
- Rubber bands/balls
- Elastic bandages
- Elastic waistbands or underwear
Please 'check' the appropriate boxes
Other - Please specify
7. Have you ever reacted after eating or handling the following?
- Apples
- Avocados
- Celery
- Bananas
- Cherries
- Chestnuts
- Ficus
- Figs
- Grapes
- Kiwis
- Latex
- Mangoes
- Melons
- Passionfruit
- Peaches
- Pears
- Pistachios
- Potatoes
- Ragweed
- Strawberry
- Tomatoes
Please select the items you have had a reaction
If you have checked any box on Questions 6 or 7, how long after contact or eating and what reaction do you usually expect to occur?
8. Specifically, have you ever experienced the following symptoms?
- Breathlessness
- Skin Redness/Rash
- Swelling of face, lips or tongue
- Congestion
- Runny nose
- Urticaria (Hives)
- Itchy or watery eyes
- Itching
- Dizziness
Please select the symptoms you have experienced
Other, please specify
9. Have you ever suffered anaphylactic shock?
- Yes
- No
If so, please detail how many times and under what conditions?
Signature
Date

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Head Office Libertatem Healthcare Group Trinity Court Molly Millars Lane, Wokingham RG41 2PY
01189 730006
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Care Search & Select Recruitment Referral Form

Care, Search & Select - Latex & Allergy Form

If you have answered yes to ANY of the questions this far then please continue to complete this form. If you have answered no to ALL of the questions this far, you may go the bottom of the form, sign date and submit it.