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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