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Allergy Questionnaire
Latex Allergy Questionnaire
Name
*
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Do you wear latex gloves regularly or are you otherwise exposed to latex regularly?
*
Yes
No
Do you have a history of eczema or other rashes on your hands?
*
Yes
No
Do you have a medical history of frequent surgeries or invasive medical procedures?
*
Yes
No
Did these take place when you were an infant?
Yes
No
Do you have a history of hay fever or other common allergies?
*
Yes
No
Do your fellow workers wear latex gloves regularly?
*
Yes
No
I Don’t know
Do you take a beta-blocker medication?
*
Yes
No
Tick any foods below that cause hives, itching of the lips or throat, or more severe symptoms when you eat or handle them:
Avocado
Apple
Pear
Celery
Carrot
Hazelnut
Kiwi
Papaya
Peach
Cherry
Plum
Apricot
Melon
Chestnut
Nectarine
Passion fruit
Tomato
Potato
Banana
Fig
Pineapple
Grape
None
Contact Dermatitis Assessment
Do you have rash, itching, cracking, chapping, scaling, or weeping of the skin from latex glove use?
Yes
No
Have these symptoms recently changed or worsened?
Yes
No
Have you used different brands of latex gloves?
Yes
No
If so, have your symptoms persisted?
Yes
No
Have you used non latex gloves?
Yes
No
If so, have you had the same or similar symptoms as with latex gloves?
Yes
No
Do these symptoms persist when you stop wearing all gloves?
Yes
No
Contact urticaria/hives assessment
When you wear or are around others wearing latex gloves, do you get hives; red, itchy, swollen hands within 30 minutes; or “water blisters” on your hands within a day
Yes
No
Aerosol reaction assessment
When you wear or are around others wearing latex gloves, have you noted any of the following conditions:
Itchy, red eyes; fits of sneezing; runny or stuffy nose; itching of the nose or palate?
Shortness of breath, wheezing, chest tightness, or difficulty breathing?
Other acute reactions, including generalized or severe swelling or shock?
History of reactions suggestive of latex allergy
Do you have a history of anaphylaxis or of intraoperative shock?
Yes
No
Have you had itching, swelling, or other symptoms following dental, rectal, or pelvic exams?
Yes
No
Have you experienced swelling or difficulty breathing after blowing up a balloon?
Yes
No
Do condoms, diaphragms, or latex sexual aids cause itching or swelling?
Yes
No
Do rubber handles, rubber bands, or elastic bands or clothing cause any discomfort?
Yes
No