Allergy Drops Questionnaire

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Questionnaire for patients on Allergy Drops

  1. (required)
  2. (required)
  3. 1. Did you miss more than 2 weeks of your allergy extracts?
  5. 2. Are you taking any new medications since your last office visit?
  7. If yes, please name:
  12. 3. Is there any change in your physical health: pregnancy, ill health?
  14. 4. Did you note any adverse reaction while using the last set of extracts?
  17. I acknowledge receiving the extracts (drops).
  20. Captcha
 

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New York Office
57 West 57th St, Suite 601,
NYC NY 10019
Call: 212.397.0157

Rockville Center Office
165 North Village
Avenue, Suite #129
Rockville Centre, NY 11570
Call: 516.678.9600

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