Allergies - Device

Allergy Symptoms Checklist

A handy checklist to record your symptoms and triggers for your healthcare provider

Use this checklist to record your symptoms and suspected triggers. Then print the form and bring it with you to your doctor or allergist. The more detail you give your doctor or allergist, the better he or she will be able to help you.

IMPORTANT: Only your doctor, allergist, or other qualified healthcare professional can provide a diagnosis of allergies. The following questionnaire is intended to help you discuss symptoms with your healthcare provider, such as an allergist. If you think you may have allergies, you should consider visiting your doctor or other qualified healthcare professional.

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Allergy Symptoms Checklist
1. Check the severity and frequency of the symptoms that you experience.
 
Severity: Runny Nose Stuffy Nose Sneezing Itchy Nose Red, Itchy, or Watery Eyes
Severe
Moderate
Mild
Frequency: Runny Nose Stuffy Nose Sneezing Itchy Nose Red, Itchy, or Watery Eyes
Daily
Weekly
Occasionally
Seasonally

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