WESTFALL SURGERY CENTER, LLP Screening Questionnaire for Latex Allergy

1. Have you ever been told by a doctor or any other health care professional that you are allergic to latex?


yes

no

Explain:

2. Have you ever experienced any of the following reactions after handling latex products such as rubber gloves or balloons?


 wheezing
 runny nose
 itching

 redness of the skin
 swelling
 hives

 other


3. Have you ever experienced any of the following reactions associated with dental work?


wheezing
 runny nose
iitching

redness of the skin
swelling
hives

other
none


4. If you experienced redness or hives, was it a localized reaction, only where your skin touched the latex product, or did it spread to your whole body?

Explain:


local

widespread

none


5. Do you have any food allergies to any of the following?



bananas
chestnuts

avocados 
kiwi

 other  
none

Explain:

6. Do you frequently or always use a bladder urine catheter?



yes

no
	




Latex allergy questionnaire reviewed by:






Comments (If appropriate):

	
	
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