What is your Last name? (Parents, please put your child's last name here)* must provide value
What is your First name? (Parents, please put your child's first name here)* must provide value
What is your date of birth? (Parents, please put your child's date of birth here)* must provide value
Today M-D-Y Please enter in your email address* must provide value
Please enter your phone number* must provide value
What is your preferred method of contact? Mark all that apply* must provide value
Email
Phone Call
Text Message
Are you the parent or legal guardian filling in the survey for your child?* must provide value
Yes
No
What is your last name (parent)? What is your first name (parent)? Have you participated in medical research previously? Yes
No
In the past 2 years, have you been involved in any medical research study? Yes
No
Please explain the type of medical research you've been involved with, including approximate date of enrollment and medication if any that were received.
How did you hear about us? Northwest Asthma and Allergy physician referral
Other physician referral
ASTHMA Inc Website
Facebook
Twitter
Craigslist
Friends
Other
What was the other way you heard about us? Please select a study area you may be interested in. Mark all that apply. Food Allergy
Asthma
Allergy Immunotherapy (New Allergy Shots or oral allergy therapy)
Urticaria (Hives)
New Drug Trials
Interested in being a healthy control
No specific interests
If there is a specific study you wish to participate in, please enter it here. What are your current medical conditions?
What medications are you taking currently?
Do any of the following conditions apply to you? (Mark all that apply) High Blood Pressure
Cancer or previous diagnosis of cancer
Diabetes
Heart Disease
High Cholesterol
Tobacco use (Current or past)
Lung Disease other than asthma
Significant Infections requiring antibiotics or antivirals in the past month
Other Serious Medical condition not listed
Has your blood pressure been consistently above 150/90? Yes
No
Do you have the diagnosis of COPD or Emphysema? Yes
No
What medications are do you take for your COPD? Albuterol (Nebulizer and/or inhalers)
LABA (Serovent, Foradil)
Muscarinic agonist (Spiriva,Ipratropium nebs)
Combination inhaler (Advair, Symbicort, Dulera)
Oxygen
Other
What is your "other" treatment for your COPD? Please describe your current lung disease (Specify your age of diagnosis, current treatments and if this is still a problem).
Do you currently smoke tobacco products? Yes
No
How many packs of cigarettes a day do you smoke? How many years have you smoked tobacco? What year did you quit? On average, how many packs of cigarettes a day did you smoke? How many years did you smoke tobacco? What is your "other" serious medical condition?
Do you have a history of allergies? i.e. asthma, nasal allergies, atopic dermatitis (eczema), food allergies Yes
No
Do you have a history of asthma? Yes
No
How well is your asthma under control? Extremely Well Controlled
Moderately controlled
Poorly Controlled
Uncontrolled
Have you had an asthma exacerbation in the past year? Yes
No
Have you ever been admitted to a hospital for your asthma? Yes
No
Have you ever been to the intensive care unit, intubated (breathing tube) or put on a ventilator for your asthma? Yes
No
What was the approximate date of when your asthma was so bad that it required intubation (breathing tube), ICU stay or required a ventilator? Do NSAIDs (aspirin, ibuprofen, naproxen alleve) make your asthma worse? Yes
No
Do you have nasal polyps and/or have require surgery to remove polyps? Yes
No
What do you currently use to treat your asthma? Albuterol inhaler (i.e. Proventil, Xopenex) as needed
Controller Steroid Inhaler (Q-var, Flovent, Asmanex)
Controller Combination Inhaler (Advair, Symbicort, Dulera)
Daily oral steroids (prednisone, prednisolone)
Xolair
Leukotriene Inhibitor (Singulair, montelukast, Zileuton)
No current treatment
In past 4 weeks how often have you used your albuerol rescue inhaler? 3 or more times per day
1-2 times per day
2 or 3 times per week
once or twice
Not at all
What is the product name and dose (i.e. # of puffs twice a day) for your asthma controller (steroid or combo) inhaler? Do you have nasal allergies (ie. hay fever, sneezing, stuffy nose, runny nose, post nasal drip)? Yes
No
Do you have a history of nasal polyps and/or have had surgery removing nasal polyps? Yes
No
What are your allergy triggers? (Mark all that apply) Grass
Tree Pollen
Weeds
Molds
Dust Mite
Cats
Dog
Other
Do not know
What do you use to treat your nasal allergies? (Mark all the apply) Antihistamines (Benadryl, Claritin, Zyrtec, Allegra)
Nasal Steroids (Flonase, Nasacort, Nasonex, Fluticasone)
Montelukast (Singulair)
Allergy Immunotherapy (aka Allergy shots)
Oral Immunotherapy (Grasstek, ragutek)
Daily Sinus Rinse
No treatment
Other
Are you currently on allergy immunotherapy? ("Allergy shots") Yes, currently
No but have been on allergy shots in the past
What are your "other" treatments of your nasal allergy? What are your "other" triggers for your nasal allergies? Do you have eczema or atopic dermatitis? Yes
No
What do you use to treat your eczema? (Choose all that apply) Moisturizers
Topical Steroids
Oral Steroids
Other
What other medication do you use to treat your eczema? Do you have a diagnosis of food allergies? Yes
No
Do you have an epinephrine injector for your food allergies? Yes
No
What are your food allergies both past and present? (Mark all that apply) Peanut
Tree Nut or Seeds
Milk
Egg
Wheat
Soy
Fish
Shellfish
Other
How old were you when you were diagnosed with peanut allergy? Has your peanut allergy resolved? Yes
No
How old were you when your peanut allergy resolved? What best describes your reaction to peanut? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
What medications do you use to treat your reactions to peanuts? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction(s) to peanut.
Please describe your reaction to peanut.
Which tree nuts or seeds do you have a reaction? (Mark all that apply) Almond
Cashew
Walnut
Pecan
Macadamia
Brazil Nut
Pistacchio
Sesame seeds
Pine Nut
Sunflower seeds
How old were you when you were diagnosed with tree nut or seed allergy? Has your tree nut or seed allergy resolved? Yes
No
How old were you when your tree nut or seed allergy resolved? What best describes your reaction to tree nuts/seeds? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
What medications do you use to treat your reactions to tree nuts/seeds? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction(s) to the specific tree nuts/seeds.
Describe your reaction to tree nuts/seeds.
How old were you when you were diagnosed with egg allergy? Has your egg allergy resolved? Yes
No
How old were you when your egg allergy resolved? What best describes your reaction to egg? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
What medications do you use to treat your reactions to egg? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction(s) to egg.
Please describe your reaction to egg.
How old were you when you were diagnosed with milk allergy? Has your milk allergy resolved? Yes
No
How old were you when your milk allergy resolved? What best describes your reaction to milk? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
What medications do you use to treat your reactions to milk? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction to milk.
Describe your reaction to milk.
How old were you when you were diagnosed with wheat allergy? Has your wheat allergy resolved? Yes
No
How old were you when your wheat allergy resolved? What best describes your reaction to wheat? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
What medications do you use to treat your reactions to wheat? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction to wheat.
Describe your reaction to wheat?
How old were you diagnosed when you were diagnosed with soy allergy? Has your soy allergy resolved? Yes
No
How old were you when your soy allergy resolved? What best describes your reaction to soy? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
Please describe your reaction soy.
What do you use to treat reactions to soy? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction to soy.
How old were you when you were diagnosed with fish allergy? Has your fish allergy resolved? Yes
No
How old were you when your fish allergy resolved? What best describes your reaction to fish? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
What do you use to treat reactions to fish? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction to fish.
Describe your reaction fish
How old were you when you were diagnosed with shellfish allergy? Has your shellfish allergy resolved? Yes
No
How old were you when your shellfish allergy resolved? What best describes your reaction to shellfish ? (Mark all that apply) Itchy mouth or throat
Wheezing
Hives/itchy skin
Abdominal Pain
Diarrhea
Vomiting
Severe reaction (Anaphylaxis)
Never had a reaction, detected by testing only
Other
What do you use to treat reactions to shellfish? (Mark all that apply) Antihistamine (i.e. benadryl, zyrtec, claritin)
Epinephrine Autoinjector
Albuterol inhaler
H2 blocker (pepcid, zantac)
Topical Steroids
Oral Steroids
N/A, never consumed the food
Please describe your severe reaction to shellfish.
Describe your reaction to shellfish
Please identify your other food allergies. Specify your age when you were diagnosed, if they are still a problem and your reactions.
Have you ever had a severe allergic reaction (i.e. anaphylaxis) to anything other than food? Yes
No
Do you carry an epinephrine autoinjector? (ie Epipen, Auvi-Q) Yes
No
Please describe what occurred. Specify your age when you this episode of anaphylaxis occurred, treatment needed and if this is still a problem)
Do you have history with chronic or recurrent hives? Yes
No
Have you had daily hives for more than 6 weeks continuously? Yes
No
What do you use to treat your hives? Mark all that apply including past treatments. High Dose Antihistamines
Cyclosporine
Omalizumab (Xolair)
Mycophenolic acid
Montelukast (Singulair)
Topical Steroids
Prednisone
Other
What "other" treatment do you use to treat your chronic hives?
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