Allergy Symptom Screening

Please fill out the form below and submit prior to your upcoming appointment. If you do not already have an appointment but would like to be screened for allergies, feel free to submit the form and our office will be in touch within 72 hours. If you have any questions please call the office.

First Name

Last Name

Date of Birth (mm/dd/yyyy)

Patient Status

Phone Number

Email Address

Itchy Eyes Severity

Itchy Eyes Frequency

Watery Eyes Severity

Watery Eyes Frequency

Red Eyes Severity

Red Eyes Frequency

Runny Nose Severity

Runny Nose Frequency

Itchy Nose Severity

Itchy Nose Frequency

Stuffy Nose Severity

Stuffy Nose Frequency

Frequent Sneezing Severity

Sneezing Frequency

Have you ever been diagnosed with asthma? Have you ever been diagnosed with asthma? Yes No

Have you ever been diagnosed with atopic dermatitis? Have you ever been diagnosed with atopic dermatitis? Yes No

Do you take prescription or over the counter medications to manage your allergy symptoms? Do you take prescription or over the counter medications to manage your allergy symptoms? Yes No

Name your medications and last date taken: