Create a Personalized Allergy Guide

Patient is ?* Please Select Adult Child Only characters

Q1. Which of the following symptoms do you & your child experience? Runny Nose Blocked Nose Itchy-Red Eyes Sneezing Wheezing Breathing Difficulties Coughing Chest Tightness Frequently loose motion Stomach Pain Ear Infection Diarrhoea

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Q2. How long have these symptoms been present?* Please Select Since Birth For the past several months For the past several years Just recently Only characters

Q3. Do you or your child’s symptoms disturb you or your child’s sleep?* Please Select Yes No Only characters

Q4. When do the symptoms occur?* Please Select In the Spring/Summer In the Autumm Year Round In the winter Only characters

Q5. Do you think you have allergies?* Please Select Yes No Only characters

Your Name

eg. 1234567890

Any other quires please mention here: Only Characters

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