Allergy Screening Quiz

Please take the time to answer the following questions. These questions are intended to act as a guide, showing how affected you are by allergic type symptoms. Once you have completed the questionnaire you can print the results page and hand it to your doctor, or nurse. Your answers are completely confidential and are not recorded.

if you answer "yes" or "frequently" to any of these questions you may want to consult with one of our health care providers. The results of this self assessment quiz are not to be considered as medical advice or diagnoses.

1. In the course of a year, how often are the following symptoms experienced? Never /
Occasionally		 Frequently
Itchy nose 0 2
Urge to sneeze, sneezing fits 0 1
Runny nose, rhinitis 0 1
Stuffy nose 0 1
Itching, burning, red eyes 0 1
2. Are these symptoms particularly frequent or severe. No Yes
...in spring or summer? 0 3
...when close to meadows, fields or trees? 0 5
...when close to animals? (cats, dogs, horses,etc.) 0 3
...when lying in bed at night? 0 1
...in rooms with rugs or wall-to-wall carpets? 0 2
...when eating particular foods? 0 2

3. When these symptoms are experienced, what is the level of illness felt on that day?

Do not feel ill at all Feel very ill
0 1 2 3 4 5 6 7 8 9 10
0 points 2 points

Contact Dr. L.A. Torres Jr.
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Dr. L.A. Torres Jr. M.D.
4601 Old Shepard Pl.
Building One, Suite 101
Plano, Texas 75093

Phone: 214-919-2350
Fax: 214-919-2361
Dr. L.A. Torres Jr. M.D.