allergy screening questionnaire
Please take a short while to answer the following questions. These questions are intended to act as a guide, showing how affected you, or your child, are by allergic type symptoms.
Once you have completed the questionnaire you can print the page and hand it to your doctor, or nurse.
Your answers are completely confidential and are not recorded.
Frequently
Never / Occasionally
1 In the course of a year, how often are the following symptoms experienced?
Urge to sneeze, sneezing fits
Itching, burning, red eyes
Yes
No
2 Are these symptoms particularly frequent or severe...
...when close to meadows, fields or trees?
...when close to animals? (cats, dogs, horses,etc.)
...when lying in bed at night?
...in rooms with rugs or wall-to-wall carpets?
...when eating particular foods?
3 When these symptoms are experienced, what is the level of illness felt on that day?
Do not feel ill at all
Feel very ill
0
1
2
3
4
5
6
7
8
9
10
Total Score:
0
A score of 7 or more indicates the likelihood of an allergic respiratory disease, commonly known as hay fever. Don't let hay fever get the better of you (or your child), speak to your doctor.
Yes
No
Ever been diagnosed by a doctor as having allergy to...
...mites, house dust mites?