» Allergy Questionnaire

Name*

First

Last

Date of Birth

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:

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

Latex Allergy Questionnaire

Contact Dermatitis Assessment

Contact urticaria/hives assessment

Aerosol reaction assessment

History of reactions suggestive of latex allergy