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Chronic Hives Questionnaire

Skin Seriously.

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Chronic Hives Questionnaire

Skin Seriously.

Chronic Hives Questionnaire

  • Date of onset of hives?
  • How often are the attacks? (i.e. daily, weekly, monthly)
  • How long do they last?
  • What time of day are the symptoms most severe? (i.e. mornings, evenings, after meals)
  • What parts of the body are usually affected first, if any?
  • Do the attacks occur more frequently during a specific time of year? (i.e. winter, spring, fall, summer)
  • Do any of the following produce hives:
  • Heat exposure
  • Exercise
  • Sunlight Exposure
  • Rainy or wet periods
  • Damp rooms/area (molds)
  • Bathing or showering
  • Pressure, prolonged sitting
  • Vibration
  • Rubbing or scratching
  • Friction, clothing contact
  • Do the attacks happen when you come into contact with anything specific? Be specific (i.e. animals, fumes, cosmetics, soaps)
  • Do they appear during your menstrual periods?
  • Do they appear when you are stressed?
  • Are you pregnant?
  • Do hives seem to occur in relation to of the following:
  • Indoors only or predominantly
  • Rooms or locations in particular (i.e workshop, basement)
  • Outdoors only or predominantly
  • At work
  • At home
  • During weekdays predominantly
  • On weekends predominantly
  • During recreational activities
  • Housework
  • At a specific location
  • Have you recently had any of the following infections or symptoms of infections?
  • Sore throat, strep throat
  • Swollen lymph glands
  • Mononucleosis
  • Impetigo, skin infections
  • Jaundice/ hepatitis
  • Pneumonia
  • Yeast infection
  • Painful urination, urinary tract infection
  • Gallbladder infection
  • Fungal infection of skin, hair, nails
  • Tooth/gum infection
  • Do you have a history of allergies or allergic symptoms?
  • List all prescription drugs taken within the last year, including those that have been discontinued. Please include any topical creams and injectable medications:
  • List all over the counter drugs taken within the last year. Please include cosmetics in this list?
  • Have you noticed that particular foods cause hives, swelling of the lips or tongue, sinus congestion, nausea, abdominal pain, or difficulty breathing? Please list foods and accompanying symptoms.
  • Please list previous treatments tried for the hives:
  • Steroids:
  • Antihistamines:
  • Epinephrine:
  • Dietary elimination-type:
  • Antibiotics:
  • Other:
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