Pre-consultation: Kenalog Hay Fever

First name *

Last name *

Email *

Phone *

Date of birth *

How severe are your hay fever symptoms? *

Mild (occasional sniffles)

Moderate (interferes with daily activities some days)

Severe (significantly impacts daily activities most days)

Debilitating (unable to function normally)

Which symptoms do you experience? *

Select all that apply

Sneezing

Runny nose

Blocked nose

Itchy eyes

Watery eyes

Itchy throat

Cough

Wheezing

Fatigue

Headache

How many months per year are you affected by hay fever? *

Enter number of months

Which months are worst? (e.g. March-May, August-October)

How does hay fever impact your work or studies?

No impact

Minor impact

Moderate impact (miss some days)

Severe impact (significant absences)

Does it affect your sleep?

No

Yes, sometimes

Yes, most nights during season

Does it affect your exercise or outdoor activities?

No

Yes, sometimes

Yes, significantly limits activities

Which nasal sprays have you used?

Include brand name and effectiveness

Have you had a Kenalog injection before? *

No

Yes

When was your last Kenalog injection?

How effective was it for you?

Not effective

Mildly effective

Moderately effective

Very effective

Did you experience any side effects from Kenalog?

No

Yes

Do you have diabetes? *

Kenalog can temporarily raise blood sugar levels

No

Yes, type 1

Yes, type 2

Yes, prediabetic

Are you immunosuppressed or taking immunosuppressive medications? *

No

Yes

Do you currently have an active infection? *

No

Yes

Do you have osteoporosis or weak bones?

No

Yes

Do you have high blood pressure?

No

Yes, controlled

Yes, uncontrolled

Do you have glaucoma or other eye pressure issues?

No

Yes

Are you pregnant or breastfeeding? *

Kenalog is contraindicated in pregnancy and breastfeeding

N/A

No

Yes, pregnant

Yes, breastfeeding

Do you have an allergy to corticosteroids? *

No

Yes

What medications are you currently taking?

Include all prescriptions and regular over-the-counter medications

What are your goals for hay fever treatment?

What outcome would make the biggest difference to your quality of life?

Here's what you've told us. Have a quick check, then hit send - this means your consultation can focus on what actually matters to you.

Your details

Name

Email

Phone

Date of birth

Your Hay Fever Symptoms

How severe are your hay fever symptoms? -

Which symptoms do you experience? -

How many months per year are you affected by hay fever? -

Which months are worst? (e.g. March-May, August-October) -

Impact on Daily Life

How does hay fever impact your work or studies? -

Does it affect your sleep? -

Does it affect your exercise or outdoor activities? -

Treatments Tried

Which nasal sprays have you used? -

Previous Kenalog Experience

Have you had a Kenalog injection before? -

When was your last Kenalog injection? -

How effective was it for you? -

Did you experience any side effects from Kenalog? -

Medical Safety Check

Do you have diabetes? -

Are you immunosuppressed or taking immunosuppressive medications? -

Do you currently have an active infection? -

Do you have osteoporosis or weak bones? -

Do you have high blood pressure? -

Do you have glaucoma or other eye pressure issues? -

Are you pregnant or breastfeeding? -

Do you have an allergy to corticosteroids? -

Current Medications & Goals

What medications are you currently taking? -

What are your goals for hay fever treatment? -

Upload previous Kenalog records or allergy test results (optional)

If you've had Kenalog before, share any documentation. Allergy test results also helpful.

Click to upload files

Anything else for your doctor?