Questionnaire | London Allergy & Immunology Centre

Section 5 - Food Allergies
Do you have any food allergies?
- Yes
- No
Please give details of any food allergies/sensitivity and briefly describe the reaction. Please state if the reaction is immediate or delayed:
If any, please give details of foods you avoid and why:

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

I agree to provide a blood sample via the Home Collection method, 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
Prices and what do I do next? This is a required field.*
- The cost of this test is £393 - I will send a labelled sample with the patient's name and date of birth clearly written on it after self collection from a finger prick (video instructions are available on-line), or will attend a lab in central London where a healthcare professional will take a sample (for children or if you are not able to take the sample yourself)
Additional Comments

Section 1 - About You