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Allergy & Health Questionnaire 2:

Please complete this ASAP or at least 1 week before your visit. Give your best guess if you cannot remember all of the details. Complete all applicable items.
Your Name:    Date of Birth:    Your Age:   
  Duration   Duration   Duration   Duration
Skin: Itching
   
Rash
   
Hives:
   
Others:
   
Eyes: Itchy
Tearing:
Redness:
Burning:
Ears: Itchy
Plugged:
Hearing Loss:
Aches:
Nose: Stuffy
Runny:
Sneezing:
Itchy:
Throat: Itchy
Hoarse:
Sore:
Burning:
Sinus: Pains
Discharge:
Impaired smell function:
Lungs: Cough
Wheeze:
Short of Breathe:
Chest Tightness
Headaches:
   Throbbing
Vise-Like:
Pressure: