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Allergy Questionnaire - Broomfield Family Practice

Allergy Questionnaire Symbia Allergy Solutions Fax: 303-379-7385 Patient Name: _____ DOB: _____ Date: _____ (*If you are the parent filling out this form for your child(ren), please fill out only one form for the entire Family . It is NOT necessary to fill out one for each child.) Email: _____ Do you suffer from seasonal or year round allergies? Yes No Do you experience any of the following symptoms? Please check all that apply. ___ Runny Nose ___ Itchy Eyes ___ Skin Rashes ___ Nasal Congestion ___ Fibromyalgia ___ Vertigo ___ Post Nasal Drip ___ Headache ___ Tinnitus ___ Sinusitis ___ Watery Eyes ___ Meniere s Disease ___ Asthma ___ Eczema/ Atopic Dermatitis ___Fatigue/ Trouble Sleeping ___ Diarrhea ___ Irritable Bowel Syndrome ___ Pre-Menstrual Syndrome Other Symptoms _____ Would you like to consult with a provider at Broomfield Family Practice to discuss Allergy treatment options?

Allergy Questionnaire Symbia Allergy Solutions Fax: 303-379-7385 Patient Name: _____ DOB: _____ Date: _____

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Transcription of Allergy Questionnaire - Broomfield Family Practice

1 Allergy Questionnaire Symbia Allergy Solutions Fax: 303-379-7385 Patient Name: _____ DOB: _____ Date: _____ (*If you are the parent filling out this form for your child(ren), please fill out only one form for the entire Family . It is NOT necessary to fill out one for each child.) Email: _____ Do you suffer from seasonal or year round allergies? Yes No Do you experience any of the following symptoms? Please check all that apply. ___ Runny Nose ___ Itchy Eyes ___ Skin Rashes ___ Nasal Congestion ___ Fibromyalgia ___ Vertigo ___ Post Nasal Drip ___ Headache ___ Tinnitus ___ Sinusitis ___ Watery Eyes ___ Meniere s Disease ___ Asthma ___ Eczema/ Atopic Dermatitis ___Fatigue/ Trouble Sleeping ___ Diarrhea ___ Irritable Bowel Syndrome ___ Pre-Menstrual Syndrome Other Symptoms _____ Would you like to consult with a provider at Broomfield Family Practice to discuss Allergy treatment options?

2 Yes No Signature _____


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