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©The Author(s) 2023.
World J Gastrointest Endosc. May 16, 2023; 15(5): 407-419
Published online May 16, 2023. doi: 10.4253/wjge.v15.i5.407
Published online May 16, 2023. doi: 10.4253/wjge.v15.i5.407
Table 1 Atopy screening questionnaire
Atopy screening questionnaire |
(1) Has the patient ever been allergy tested? |
Yes |
No |
(2) Has the patient ever been on allergy shots? |
Yes |
No |
(3) In past 12 mo, has the patient had the following symptoms lasting for > 4 wk at a time? (Check all that apply) |
Itching of eyes or nose |
Sneezing |
Stuffiness of nose |
Seasonal or year-round runny nose |
Eye itching/tearing/redness |
(4) What seasons are the above symptoms most noticeable? (Check all that apply) Spring |
Summer |
Fall |
Winter |
Year-round |
(5) Has the patient ever had one of the following? (Check all that apply) |
Doctor diagnosed “allergic rhinitis” |
Doctor diagnosed “allergic conjunctivitis” |
(6) In past 12 mo, has the patient had any of the following skin symptoms lasting > 4 wk at a time? (Check all that apply) |
Itchy skin |
Red skin |
Bumpy skin |
Rash on the face, or at the elbow, or knee joints, behind the ear, tops of feet, wrists |
Rash that you have put steroid cream on (hydrocortisone, triamcinolone) |
(7) Has the patient ever had doctor diagnosed “eczema”? |
Yes |
No |
(8) Has the patient ever had doctor diagnosed “reactive airways disease,” “asthma,” or “chronic bronchitis?” |
Yes |
No |
(9) In the past 12 mo, has the patient ever required the use of an inhaler or nebulizer? |
Yes |
No |
(10) In the past 12 mo, has the patient had any of the following respiratory symptoms that have lasted > 2 wk at a time? (Check all that apply) |
Wheeze |
Shortness of breath |
Difficulty breathing |
Sputum production |
Chest pain/tightness |
Cough |
Nighttime wakening from cough |
Exercise that required the use of an inhaler to help breathe |
(11) Has the patient taken any of the following medications in the past year? (Check all that apply) |
- Citation: Kaur P, Chevalier R, Friesen C, Ryan J, Sherman A, Page S. Diagnostic role of fractional exhaled nitric oxide in pediatric eosinophilic esophagitis, relationship with gastric and duodenal eosinophils. World J Gastrointest Endosc 2023; 15(5): 407-419
- URL: https://www.wjgnet.com/1948-5190/full/v15/i5/407.htm
- DOI: https://dx.doi.org/10.4253/wjge.v15.i5.407