Questionnaire allergies

By means of the questions below, we would like to make a first assessment of the severity of the allergy. Please complete the following questionnaire prior to your first appointment at the hospital. Where the text says "you", this also means "your child".

Thank you and we look forward to seeing you at the Paediatric Outpatient Clinic of Amstelland Hospital.

Name *

Date of birth *

Date of appointment at outpatient clinic

Inhaled allergy / possible hay fever symptoms

Nose

Please tick the box that applies to you:

Sneezing

Runny nose

Stuffy nose

Itching

Eyes

Please tick the box that applies to you:

Redness

Itching

Swollen

Watery

Airways

Please tick the box that applies to you:

Coughing

Wheezing

Shortness of breath

Other, namely:

Have you ever had an allergic reaction to a wasp or bee sting?

Yes

Other, namely:

Other allergies

Have you ever had an allergic reaction to food?

Yes

Cashews: At what quantity?

Almonds: At what quantity?

Hazelnuts: At what quantity?

Walnuts: At what quantity?

Pistachios: At what quantity?

Which other nut? And at what quantity?

Eggs: Processed or unprocessed?

Sesame seeds: Cooked or uncooked?

Which fruit?

Other, namely:

How long after eating did the symptoms occur?

Medical information

Does anyone in your family suffer from allergies, eczema and /or asthma?

Yes

Who and which condition?

Do you suffer from eczema or have you had eczema in the past?

Yes

Do you use medication for your allergy?

Yes

Which one?

Do you use any other medications?

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