Allergy Trial Questionnaire
Name:
Address:
Phone:
How far are you willing to travel to do the allergy trial?
How soon would you like to complete the allergy trial?
|
Name/Age |
Are you allergic to any of these things? Please mark all that apply for each family member. And indicate the severity of reaction to each of the allergens. Use a scale of 1-10 with 1 = very mild, hardly noticeable to others and 10= life threatening if emergency attention is not received immediately. Please describe your typical reaction to each of the allergens. For example, runny nose, watery/itchy eyes, sneezing, coughing, hives, rash, asthma, etc. |
||||||||
|
Dogs |
Cats |
Dust |
Mold |
Pollen/grasses/ trees |
Cockroach dust |
Perfume/ fragrance |
Candles |
Other (please list) |
|
Have the above allergies been documented by a physician?
How long have you had the above allergies? For example, all your life, following a pregnancy, developed as an adult, etc.
How have your allergies changed in severity in the last few years? In other words, have they stayed the same, worsened, or improved? Please describe.
What types of allergy medications are you on regularly?
What medication do you take on an emergency or as needed basis?
How effective are your medications are reducing/eliminating the symptoms?
Do you have any environmental modifications in place to help eliminate allergic reactions? For example, do you have hepa air filtration in your air conditioning, hepa filters for specific rooms, ability to close off areas, special flooring, etc.
Is there anything else we need to know about you/your allergies?
Are you willing to accept responsibility for any/all reaction(s) you and/or your family members may experience during the allergy trial? In other words, you will not hold the referring breeder and/or AHT owner responsible for any illness or injury that may result from your visit and subsequent exposure to the allergens in the environment.
Take
me back to the top!
Previous
Page |
Next
Page | Home
|
Site
Map |
Email
Us
Website design and header graphics by:WUDNSHU. Wudnshu AHT Logo designed by Argostar.
Standard and logo used with permission of the AHTA.
This site ©2006 Wudnshu AHTs unless otherwise noted.