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Allergy questionnaire

If you are unclear about how to complete the questionnaire, we will be happy to discuss this with you during consultation hours. We also welcome feedback on the questionnaire.

Present complaints

First name *

Last name *

Date of birth *

Present complaints *

Eye inflammation

Common cold

Sneezing fits

Bronchitis

Irritant cough

Hives

Eczema

Asthma attacks

Swelling (e.g. eyes, lips, tongue)

Gastrointestinal complaints (e.g. diarrhea)

Onset of ocular inflammation? *

Start of the sniffles? *

Onset of sneezing attacks? *

Beginning of bronchitis? *

Onset of irritable cough? *

Beginning of hives? *

Onset of eczema? *

Onset of asthma attacks? *

Onset of swelling (e.g., eyes, lips, tongue)? *

Onset of gastrointestinal symptoms (e.g. diarrhea)? *

If you are human, leave this field blank.

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