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HAYFEVER FOLLOW-UP QUESTIONNAIRE

HAYFEVER TREATMENT FOLLOW-UP FORM

TWO WEEK POST TREATMENT FOLLOW UP

Thank you for attending your hayfever treatment appointment. We would like to assess your response to the treatment and ensure you are satisfied with the outcome. Please complete this form based on your experience over the past two weeks.

Personal Data

Birthday
Day
Month
Year
Treatment taken
What are your current level of severity of symptoms? (1 mild - 10 Horrendous)
1
2
3
4
5
6
7
8
9
10
Would you say overall your symptoms have improved
Yes, significantly
Yes, Slightly
No change
Worse than before
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By Clicking submit you are confirming that the information provided is to the best of your knowledge true and accurate. Any information that is not disclosed may affect the decision the clinician makes, and may affect your health. In the instance of withheld information the clinician is not responsible for any adverse effects of treatment

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