Q1: I have rhinitis: yes/no |
Q2: I have asthma: yes/no |
Q3: My symptoms (tick) |
Runny nose |
Itchy nose |
Sneezing |
Congestion (blocked nose) |
Red eyes |
Itchy eyes |
Watery eyes |
Q4: How they affect me: my symptoms (tick) |
Affect my sleep |
Restrict my daily activities |
Restrict my participation in school or work |
Are troublesome |
Q5: Medications |
Q6: Are you currently receiving immunotherapy (a small dose of the thing you are allergic to, usually taken as an injection or placed under your tongue)? yes/no |
If YES to Q6 (Q7 and Q8) |
Q7: What allergy is this? |
Grass pollen |
Parietaria pollen |
Birch pollen |
Other pollen |
Dust mite |
Animal |
Cypress tree pollen |
Don’t know |
Add allergy |
Q8: How do you receive your treatment? |
Injection |
Tablet under the tongue |
Drops under the tongue |
Spray under the tongue |
Other |