Allergy Assessment - Kids Central Pediatrics

*Parent First Name

*Parent Last Name

*Email *Phone

*Patient First Name

*Patient Last Name

*Patient Date of Birth

*Patient Gender

Male Female

*Itchy Eyes

Severity

None Mild Moderate Severe

Frequency

Occasionally / Never Seasonal Constant/Daily

*Watery Eyes

Severity

None Mild Moderate Severe

Frequency

Occasionally / Never Seasonal Constant/Daily

*Red Eyes

Severity

None Mild Moderate Severe

Frequency

Occasionally / Never Seasonal Constant/Daily

*Runny Nose

Severity

None Mild Moderate Severe

Frequency

Occasionally / Never Seasonal Constant/Daily

*Itchy Nose

Severity

None Mild Moderate Severe

Frequency

Occasionally / Never Seasonal Constant/Daily

*Stuffy Nose

Severity

None Mild Moderate Severe

Frequency

Occasionally / Never Seasonal Constant/Daily

*Frequent Sneezing

Severity

None Mild Moderate Severe

Frequency

Occasionally / Never Seasonal Constant/Daily

Previous Diagnosis

*Have you ever been diagnosed with asthma?

YES NO

*Have you ever been diagnosed with atopic dermatitis?

YES NO

*Do you take prescription or over-the-counter medications to manage your allergy symptoms?

YES NO

*List any of the above medications and last date taken: