ALLERGY INSTITUTE

A.M. Aminian, M.D.

SELF EVALUATION

Do you or your child have allergies?

Select all symptoms that apply to you or your child and find out! Select all symptoms that apply to you or your child. If you have experienced 3 or more of these symptoms, you may suffer from allergies. Please submit the information and receive more information from the Allergy Institute. We would be pleased to see you and help you get back on the road to a full, enjoyable life!

Do you or your child have asthma?

Fresno (559) 447-1700 Visalia (559) 627-9107

	Rash Itchy, watery eyes Stuffy nose, runny nose, or post-nasal drip Nose and ears feel plugged Difficulty breathing, shortness of breath Itchiness Green or yellow nasal mucous
Fist Name: *
Last Name: *
Phone:
Email:

	Frequent cough, especially at night Shortness of breath Feel tired or weak when exercising Wheezing or coughing after exercising Feel tired, easily upset, grouchy, or moody Signs of a cold or allergies Trouble sleeping
First Name: *
Last Name: *
Phone:
Email