Allergy Self-Test – Allergy Treatment NY

Your Name *

Your Phone *

Your Email *

Have you ever been diagnosed with, or do you think you might have, environmental allergies? *

Yes
No

Do you ever experience any of the following symptoms?

If you have any of the above symptoms, are they worse:

Do you have, or have you ever had:

Eczema
Asthma
Sinus issues
Post nasal drip

Do you get frequent colds? *

Yes
No

Do you use any over-the-counter products or prescription medications such as artificial tears, allergy eye, nose or ear drops, nasal sprays, anti-histamine pills (such as Claritan, Allegra, Zyrtek, Pseudophed, Benadryl, etc.)? *

Yes
No