Allergy History Form
Name *
Your answer
Email *
Your answer
Phone number
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Profession / Occupation: *
Your answer
Any Current Symptoms:
Your answer
Significant Medical History
(Asthma, Bronchitis, Skin Rash, Itching, Sneezing, Watering Eyes, Rhinits etc) Please Specify
Your answer
Have you been admitted to a hospital for allergy treatment? Yes / No
If yes, please give details
Your answer
Do you smoke? *
Do you consume alcohol? *
Are you currently on any medications? Yes / No *
If yes, give details
Your answer
Do you take Vitamins / Calcium supplements? Yes / No *
If yes, give details
Your answer
Your Diet *
Required
Do you have any pets or exposure to pets (cats/dogs)? Yes / No *
Your answer
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