Latex Sensitivity Questionnaire
1. Do you suffer from:
Seasonal Hay Fever
Yes
No
Eczema
Yes
No
Autoimmune Disease
Yes
No
Chronic Asthma
Yes
No
2. Do you have any food allergies?
Yes
No
3. Do you have on-the-job exposure to latex?
Yes
No
4. Have you ever been told by a doctor that you are allergic to latex?
Yes
No
5. Have you experienced allergic symptoms after contact with latex or rubber?
Yes
No
If YES, do the symptoms include any of the following? (Check all that apply)
Hives
Itching
Difficulty Breathing
Wheezing
Watery eyes
6. Have you ever had allergic symptoms while: (Check all that apply)
Blowing up balloons
During dental examinations
While wearing rubber gloves
7. Have you ever had a strong allergic reaction (anaphylaxis) or other unexplained reaction during or following a medical procedure?
Yes
No