Allergy Risk Assessment Form

Helps healthcare providers map out a patient's allergy history, symptoms, and the triggers that make their condition worse.

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Full Name

Nombre

Apellido

Phone Number

What is your age?

Have you ever been diagnosed with allergies?

If yes, please specify the type of allergies.

Have you experienced any of the following symptoms?

Hives Swelling Difficulty breathing Itching Other

If you selected 'Other' above, please specify

Do your symptoms worsen in certain environments (e.g. outdoors, indoors, during specific seasons)?

Yes No

Have you experienced any severe or life-threatening allergic reactions (e.g. anaphylaxis)?

Yes No

If yes, please describe the reaction(s).

Have you undergone any allergy testing (e.g. skin prick test, blood test)?

If yes, please specify the type of allergy testing.

Do you take any allergy medications?

Yes No

If yes, please specify the medications you take.

Is there anything else you'd like to share about your allergies or symptoms?

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