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Allergy Testing Questionnaire

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Have you been Allergy Tested before?
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Why are you needing Allergy Testing?

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Do your symptoms flare up often?
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Are you diagnosed with Upper Respiratory Infections more than 3 times per year?
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Did you have your current allergy symptoms at your previous residence?
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Do you have a Family History of Asthma?
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Have you been diagnosed with Asthma?
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Have you taken/used any of the following medications within the last week?

Have you had an Allergic Reaction that caused any of the following:

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Have you ever been Food Allergy Tested?
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If no, would you like to be tested today?
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If treatment is necessary which option do you feel like you would prefer? (Shots are weekly  /  Drops are monthly)
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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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