• Allergy History Survey

  • Date*

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  • Does this number accept text?*

  • Symptoms:

    Please select the appropriate number 0 - 3 according to severity:

    0 = absent (no symptoms evident)
    1 = mild (symptoms are present, but minimal awareness, easily tolerated)
    2 = moderate (definite awareness, bothersome, but tolerable)
    3 = severe

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  • Medications:

    How often do you take medications for your allergy symptoms?

    0 = never
    1 = occasionally (several times a month or less)
    2 = frequently (frequently)
    3 = daily 

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  • Allergy History:

  • In what season are they worse?*
  • Have you been allergy tested before?*
  • If yes, which type?
  • Have you previously received allergy shots?*
  • Have your previously used allergy drops?*
  • Do you smoke or use tobacco products?*
  • Were you referred by a physician?*
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