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Allergy Testing Form
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Allergy Wellness Update
Name
*
Date of Birth
*
Email Address
How often do you have these symptoms
Please check one box in the Severity section and Frequency section
Watery Eyes
Mild
Moderate
Severe
Itchy Eyes
Mild
Moderate
Severe
Red Eyes
Mild
Moderate
Severe
Runny Nose
Mild
Moderate
Severe
Stuffy Nose
Mild
Moderate
Severe
Itchy Nose
Mild
Moderate
Severe
Frequent Sneezing
Mild
Moderate
Severe
Post Nasal Drip
Mild
Moderate
Severe
Chronic/Seasonal Colds
Mild
Moderate
Severe
Sinus Pressure/Sinus Headaches
Mild
Moderate
Severe
Dry, Red, or Itchy Skin
Mild
Moderate
Severe
Consistent Coughing
Mild
Moderate
Severe
Asthma
Mild
Moderate
Severe
Itchy Mouth/Throat Clearing
Mild
Moderate
Severe
Restless Sleep Snoring
Mild
Moderate
Severe
Daytime Fatigue
Mild
Moderate
Severe
Watery Eyes
Never or Ocasionally
Seasonal
Most of the Year/Daily
Itchy Eyes
Never or Ocasionally
Seasonal
Most of the Year/Daily
Red Eyes
Never or Ocasionally
Seasonal
Most of the Year/Daily
Runny Nose
Never or Ocasionally
Seasonal
Most of the Year/Daily
Stuffy Nose
Never or Ocasionally
Seasonal
Most of the Year/Daily
Itchy Nose
Never or Ocasionally
Seasonal
Most of the Year/Daily
Frequent Sneezing
Never or Ocasionally
Seasonal
Most of the Year/Daily
Post Nasal Drip
Never or Ocasionally
Seasonal
Most of the Year/Daily
Chronic/Seasonal Colds
Never or Ocasionally
Seasonal
Most of the Year/Daily
Sinus Pressure/Sinus Headaches
Never or Ocasionally
Seasonal
Most of the Year/Daily
Dry, Red or Itchy Skin
Never or Ocasionally
Seasonal
Most of the Year/Daily
Consistent Coughing
Never or Ocasionally
Seasonal
Most of the Year/Daily
Asthma
Never or Ocasionally
Seasonal
Most of the Year/Daily
Itchy Mouth/Throat Clearing
Never or Ocasionally
Seasonal
Most of the Year/Daily
Restless Sleep Snoring
Never or Ocasionally
Seasonal
Most of the Year/Daily
Daytime Fatigue
Never or Ocasionally
Seasonal
Most of the Year/Daily
How often do you use the following?
Over-the-Counter Antihistamine
Never or Occasionally
Seasonal
Most of the Year/Daily
Over-the-Counter Nasal Spray
Never or Occasionally
Seasonal
Most of the Year/Daily
Prescribed Allergy Medication/Spray
Never or Occasionally
Seasonal
Most of the Year/Daily
Neti Pot
Never or Occasionally
Seasonal
Most of the Year/Daily
Steroids
Never or Occasionally
Seasonal
Most of the Year/Daily
Parent/Guardian Signature
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Today's Date : 10/30/2020