Allergy Risk Assessment Form
Please answer the following questions to assess your risk of having allergies.
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
What is your age?
Have you ever been diagnosed with allergies?
Please Select
Yes
No
If yes, please specify the type of allergies.
Have you experienced any of the following symptoms?
Sneezing
Runny or stuffy nose
Itchy or watery eyes
Coughing
Wheezing
Shortness of breath
Skin rash or hives
Digestive problems (e.g. nausea, vomiting, abdominal pain)
Other
If you selected 'Other' above, please specify
Do your symptoms worsen in certain environments (e.g. outdoors, indoors, during specific seasons)?
Yes
No
Have you experienced any severe or life-threatening allergic reactions (e.g. anaphylaxis)?
Yes
No
If yes, please describe the reaction(s).
Have you undergone any allergy testing (e.g. skin prick test, blood test)?
Please Select
Yes
No
I'm not sure
If yes, please specify the type of allergy testing.
Do you take any allergy medications?
Yes
No
If yes, please specify the medications you take.
Is there anything else you would like to share about your allergies or symptoms?
Submit
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