Allergic Rhinitis Form

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Full Name

HSN Number

DOB

Select a gender

Contact Number

Patient Information

Allergies

Pregnant

Breastfeeding/Chestfeeding

Uncontrolled asthma, recurrent or chronic sinusitis, otitis media, uncontrolled hypothyroidism

Previous diagnosis of allergic rhinitis

Medical History

Recently started a new drug and experiencing rhinitis (e.g., ASA, NSAID, ACE-inhibitor, α-blocker, β-blocker, Oral Contraceptive, etc.)

Drug History

Are any red flag symptoms present?

Shortness of breath or wheezingPersistent headache, eye, or facial painPrimarily unilateral nasal symptoms (symptoms only in one nostril)YesNo

Are symptoms typical of allergic rhinitis?

RhinorrheaItchy eyes, throat, or noseSneezingCongestionYesNo

Do symptoms correlate with exposure to an allergen?

YesNo

Duration of symptoms?

7 days or longerLess than 7 days

Severity of symptoms?

Mild (able to perform normal activities and sleep normally)Moderate to Severe (symptoms interfere significantly with normal activities and/or sleep)

Frequency of Symptoms?

Intermittent (less than 4 days/week or for less than 4 weeks)Persistent (≥ 4 days/week or for ≥ 4 weeks)

Review of Symptoms

Available: Mon - Fri: 10 AM - 6 PM, Saturday: 10 AM - 2 PM

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