Form

Full Name:

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

Phone Number (best contact)

Please enter a valid phone number.

Age

Sex

Occupation

Who referred you? (Check all that apply):

Another patientGoogle SearchOther

Allergies to:

DogsCatsBoth

How long have you had allergy symptoms?

Symptoms caused by dog and/or cat allergy (check all that apply)

Are symptoms worse with:

DogsCatsBoth about the same

Have either dogs or cats caused asthma symptoms?

YesNo

Which one?

DogCatBothN/A

How soon after pet exposure do allergy symptoms begin?

Within a few minutesAfter 30+ minutesOther

Allergy Symptoms improve with (check all that apply)

AntihistaminesOral steroidsAsthma inhalerGradual resolution over time

Do you have Asthma

YesNo

Do dogs/cats cause Asthma symptoms?

YesNo

Which symptoms bother you the most? (check all that apply)

How long do allergy symptoms last?

Few minutesFew hoursAll day or longer

Are there only certain breeds that cause allergy or Asthma symptoms?

Do you currently have pets?

YesNo

Dogs:

YesNo

How many dogs?

Cats:

YesNo

How many cats?

Are your pets..

IndoorOutdoorBoth indoors and outdoors

Does your dog sleep in your bedroom?

YesNoSometimes

Does your cat sleep in your bedroom?

YesNoSometimes

Does your cat/dog sleep in your bed?

YesNoSometimes

Do you have carpeting in your bedroom?

YesNo

If yes, how old is the carpet?

Do you use or have air purifiers?

YesNo

Were you ever tested for allergies?

YesNo

Were you allergic to any of the following? (Check all that apply)

Were allergy shots recommended?

YesNo

Were you ever on allergy shots?

YesNoShots were recommended but not started

If yes, how long were you on shots?

Did allergy shots help?

YesNoSlight improvementNot sure

Do you have asthma?

YesNoOccastionallyDogs or cats cause me to wheeze or cough

If yes, are your asthma symptoms...

Mild, occasionalModerate - use inhaler and asthma medication year roundSevere with frequent attacks, use inhaler oftenOther

Any emergency room visits for asthma or allergy attacks?

YesNo

Are you allergic to any medication?

YesNo

List any allergies to foods or medication:

List all current medications you take:

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Thank you for visiting NaturalAllergy.com, the Dog and Cat Allergy website operated by Angelo Mastrosimone, M.D. (“Website”). This Website is intended for educational purposes only, to help users learn more about oral treatment options for allergic diseases.

By accessing or using this Website, you agree to be bound by these Terms and Conditions. If you do not agree, please exit the Website immediately.

We do not make any claims to diagnose, treat, or cure any medical condition or disease. Information provided on this Website is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or another qualified health provider with any questions regarding a medical condition.

About Allergy Drops (Sublingual Immunotherapy)

Your responses to any questionnaires are used to develop a general allergy profile and do not affect your eligibility for allergy drop therapy.

Multiple clinical studies support the safety and effectiveness of allergy drops. While widely used in Europe and increasingly accepted in the U.S., some patients may not respond to this treatment.

Allergen extracts used in allergy drops are FDA-approved for injection but not for sublingual use. Their use in drop form is considered “off-label,” which is a legal and accepted practice in U.S. medicine. By using this Website and/or initiating treatment, you acknowledge and accept that allergy drops are an off-label use of FDA-approved biologics and that no guarantees of treatment outcomes are made.

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We are committed to protecting your privacy. Any personal or health information you voluntarily provide through forms or questionnaires on this Website will be used solely for the purpose of evaluating your allergy profile and will not be shared, sold, or disclosed to third parties without your consent, except as required by law. While reasonable measures are taken to safeguard data, no system can guarantee complete security.You understand that allergy drops are an off-label use of an FDA-approved biologic. You acknowledge that no guarantees or assurances have been made regarding the results of treatment.We do not support any claims to diagnose, treat, or cure any medical condition or disease.

I agree to all of the above terms:

YesNo

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Signature

*PLEASE EMAIL THIS FORM TO allergydrops123@gmail.com TO SUBMIT*

Dog & Cat Allergy Questionnaire

Section 1: Patient Information

Section 2: Main reason for this allergy consultation

Section 3: Symptoms

Pet Ownership & Environment

Section 5: Allergy History

Section 6: Asthma History

Section 7: Additional Allergies & Medications