Breathing, nose & eyes

Answer only what you know. If you are unsure, you can leave an answer blank or choose “I don’t know” when that option is available.

Last nameFirst nameDate of birthPhone or emailOccupation / educationPrimary care physicianScheduled appointment date

Medical or surgical historyChronic conditionsCurrent treatments and dosesKnown allergies or intolerances

When do the symptoms occur?

Year-roundDuring certain seasonsAll year round with worse periods

Have you noticed a peak during any of these periods?

January to March: hazel, alder, early birchApril to June: grasses / hay seasonJuly to October: ragweed, mugwort, Alternaria

On average, how many days per week?For how many consecutive weeks?

How often do you have each of these symptoms?

Bouts of sneezing

Runny nose with clear discharge

Blocked nose

Itchy nose

Red, watery or itchy eyes

Reduced or lost sense of smell

What impact have you noticed?

Disrupted sleepDaily activities, sport or leisure activities limitedSchool or work affected, fatigueSymptoms considered bothersome

Have you previously been diagnosed with asthma?

OuiNonJe ne sais pas

Which chest symptoms have you experienced?

Dry coughWheezingShortness of breath or difficulty breathingChest tightness

Describe your recent situation

Describe the frequency and circumstances in your own words. This information will be interpreted by the healthcare professional.

Respiratory symptoms during the dayNight-time symptoms or disrupted sleepUse of an inhaler or reliever treatmentImpact on your activitiesName or type of reliever treatmentThe healthcare professional will consider the treatment used alongside the reported frequency.

Number of flare-ups or exacerbations in the past 12 monthsEmergency care, hospital admissions or significant treatments

Do you currently have any of these signs?

Severe difficulty breathing at restUnable to speak normally or walkBlue lips or extremitiesConfusion, feeling faint or loss of consciousness

For severe difficulty breathing, blue lips, inability to speak or confusion, call 15 or 112 immediately.

Do you get tingling, itching or mild swelling in the mouth after eating a raw food?

OuiNonJe ne sais pas

This section describes a possible association between pollen and foods. It does not confirm the diagnosis, and a reaction extending beyond the mouth should be reported to the healthcare professional.

Type of home

HouseFlat

Other animals

Tobacco exposure

NoneActive smokingPassive smokingActive and passive

Heating or fireplace

Wood-burning stove or fireplaceGas heatingElectric heatingOther

Occupational or school exposures

Do symptoms improve at weekends or during holidays?

OuiNonJe ne sais pas

Leisure activities or hobbies involving exposure

Oral antihistamineCorticosteroid nasal sprayInhaled asthma treatment

Names, doses, duration and notes about treatments

Have you previously received allergen immunotherapy?

OuiNonJe ne sais pas

Allergy tests already performedRespiratory assessment / spirometry

Select reports or photos locallyOnly the file names appear in the PDF. The files do not leave your device and are not embedded.Free-text notes

Your respiratory summary

0 manifestation(s) bronchique(s), 0 food(s), 0 local file(s)

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SOS Allergo

Respiratory, ENT & PFAS

One pathway in six sections

Describe your recent situation