Symptom & Treatment Questionnaire

• Email Page

This short questionnaire covers important information your doctor will want to know about your nasal allergy symptoms and history. To help you prepare for the doctor's visit, answer the questions as best you can by checking the appropriate check boxes and typing answers in the empty text boxes. Then click on the Print Version button to print out the completed form that you can bring to the doctor's office, along with any other notes or questions to ask your doctor.

Your Symptoms

1. What kinds of symptoms do you have? (Check all that apply.)

   Nasal congestion / stuffy nose
   Sneezing
   Runny nose
   Itchy nose
   Other (Please explain.)
   

2. What is the symptom(s) that bothers you most?

3. How severe are your symptoms:

   a. In the morning?

   Very severe
   Moderately severe
   Not severe
   Not bothersome
   b. At night?

   Very severe
   Moderately severe
   Not severe
   Not bothersome

4. How frequently do your symptoms appear?

   Come and go throughout the year
   Remain fairly constant year-round
   Always happen during a specific time of the year
   Other (Please explain.)
   

5. When do your symptoms appear? (Check all that apply.)

   After spending time outdoors
   After cleaning the house
   When you are around animals
   Other (Please explain.)
   

6. How do your symptoms occur?

   All at once
   One after another
   Other (Please explain.)
   

7. What were your doing the last time you had symptoms?

8. How long do your symptoms usually last?

9. Is there wall-to-wall carpet in your home?

   Yes
   No

10. How much time do you spend outside?

    Much of the time
    Some time
    Very little or no time

11. What is the impact of your nasal allergy symptoms and allergies on your daily life?

Current Medications

12. What medications are you currently taking, if any—either prescription or over-the-counter—to relieve your symptoms? What is the dosage?

13. How well do they control your symptoms?

    All
    Most
    Some
    None

14. Do your medications cause side effects?

    Yes
    No

    If yes, what side effects are you experiencing?

Previous Medications

15. Are there other medications you've tried in the past—either prescription or over-the-counter—to relieve your symptoms? Why did you stop taking them?

Printable Version