Questionnaire - Free - Alleraus

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Instant access to allergy care

Tell Us About Your Symptoms
We’ll Do the Rest

This short questionnaire helps us understand your allergy symptoms, environment, and history.

Your answers allow our doctors to create a tailored blood test request and personalised

management plan. It only takes a few minutes, and your information is kept 100% secure.

Let’s Get to Know You

At Allergy Solutions, our team knows that everyone we meet is on their own unique journey toward better allergy care. We’d love to hear more about your symptoms!

Full Name *

Date Of Birth *

Email Address *

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Pre Assessment

1. We sometimes hear from people who have nasal symptoms of their allergies. Do you have any of the following (check all that apply)? *Stuffy noseRunny noseItchy nosePost-nasal drip

2. We sometimes hear from people who have more symptoms of their allergies in their throat or respiratory tract. Do you have any of the following (check all that apply)? *WheezeCoughA full, itchy or scratchy feeling in your throatAsthma

Asthma Given the potential dangers of asthma, we highly recommend proceeding with an Advanced Consultation. Please take a moment to answer the following questions.

Have you ever needed hospital for your asthma

Have you needed hospital last 12 months

3. We sometimes hear from people who have eye-related symptoms of their allergies. Do you have any of the following (check all that apply)? *Itchy eyesWatery eyesRed eyes

4. We sometimes find people’s symptoms vary based on changes in their immediate environment. Do you find your symptoms get much worse with (check all that apply): *Dry airCold airHot weatherExerciseChanges in elevation, especially on airplanes or in the mountainsPublic spaces, especially shopping centres, movie theatres, or hospitals

Let’s Differentiate

1. We often find people’s allergies are different depending on where they live and what’s around them.  Where in Australia have you lived?

Choose a region in Australia where you have lived. Your selection will help us tailor our services to your needs.

International

Overseas Allergies can differ greatly depending on where you have been in the world. Since you selected international, you can mention a place where you have lived before.

List a City or Country

2. We often find people’s environment impacts their allergy health. Do you have any pets or exposure to animals or other common triggers (check all that apply)? *CatsDogsHorsesOutdoors in natureDusty environmentsMould in my house or workplaceI work with chemicals (e.g. hairdressers, industry)I work in smoky or dusty environments (e.g. firefighters, manufacturing, lumber mills, quarries)

3. When in the year are you most bothered by your symptoms? *All year roundWorse in WinterWorse in SpringWorse in SummerWorse in Autumn

4. What time of day are you most bothered by your allergies? *In the morning when I first wake upIn the evening when I try to go to bedWhen I go outsideWhen I exercise

5. We often hear from people who are frustrated by how hard it’s been to treat their allergies. What have you tried so far (check all that apply)? *Antihistamines like Telfast, Zyrtec or ClaratyneA nasal steroid like Nasonex, RhinocortA nasal combination spray like Dymista or RyaltrisA nasal decongestant spray like Demazin or SudafedA nasal saline spray like FessA nasal rinse like FloA steroid injection like hydrocortisoneSeeing your GP for adviceSeeing another kind of practitioner, like a naturopath, chiropractor, nutritionist or homeopathImmunotherapy with an allergist, immunologist or another kind of doctor

Immunotherapy Since you have chosen Immunotherapy, we would like to gather more information about your previous treatments.

Who provided the immunotherapy treatment? *

When did you start? *

What condition were you treating? *

How did you receive the medication(e.g., injections or tablets)? *

When did you stop? *

Why did you stop? *

Did it help a lot, some, a little or not at all? *

If it helped, when did it stop helping?

Would you consider some kind of immunotherapy again?

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