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Adult Allergy Questionnaire

940 E. El Camino Real
Sunnyvale, CA 94087
harminder@homeopathicvibes.com
www.homeopathicvibes.com
Office Phone (408)737-7100
Office Fax (408)737-7102

If you have multiple answers then number them.
Types are as follow: 1. Ear Infections 2. Sinusitis 3. Pneumonia 4. Bronchitis 5. Meningitis 6. Dental Infections 7. Bladder/Kidney Infections 8. Skin Infections 9. Joint Infections 10. Gastrointestinal Infections
1. Asthma 2. Frequent Bronchitis 3. Frequent Pneumonia 4. Cystic fibrosis or Other Lung Disease 5. Hay fever/ Allergic rhinitis 6. Chronic Sinus problems 7. Hives/ Urticaria 8. Eczema 9. Migraines 10. Insect Allergy 11. Drug Allergy 12. Food Allergy 13. Celiac Disease 14. Immune disorders 15. Autoimmune disorders (Lupus, thyroid disease, Rheumatoid arthritis) 16. Inflammatory bowel disease 17. Early unexplained death in infancy 18. Frequent miscarriages
City / State / Years / Effects on Symptoms (better, worse, no change)

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