Allergy History Questionnaire

Have you had allergy testing done in the past?
Do you have animals/pets?
Do you have any feather pillows?
Do you have dust mite encasements on pillows or mattresses?
Do you have a HEPA filter?
Do you have a humidifier?
Do you have a dehumidifier?
Do you have central air conditioning?
Do you open the windows of your home?
Do you have an attic fan?
What type of heat do you have?
Do you have a fireplace?
Where do you live? Do you own or rent?
Do you own or rent?
Do you have a basement?
Do you have a crawlspace?
Is there any history of water damage in your home?
Do you smoke or have a history of smoking?
Do you live with any smokers?
If so, do they smoke inside?
Do you chew tobacco?
Do you drink?
If yes, choose what you drink:
Do you have a history of alcohol or substance abuse?
Are you on a blood thinner?

Social History

Marital status
Do you work outside the home?
Do you feel worse at work?
Are you exposed to any perfumes, chemicals, or irritants?