Please fill in the questionnaire below by placing a tick in either the Yes or No boxes for each question.

During the last year have you experienced symptoms such as nasal congestion, itching nose, watery eyes, sneezing or runny nose during the day?
Yes No

During the last year have you experienced these symptoms at night, such that they make it difficult to fall asleep or awaken you?
Yes No

Do you experience these symptoms more than one day per week?
Yes No

Do these symptoms affect your job, home activities, school work or family activities in a negative way?
Yes No

Do you find that your asthma tends to get worse when these symptoms occur?
Yes No

If you answer Yes to any of these questions you should discuss your symptoms with your doctor who will be able to help you find an appropriate treatment.

Print this form and bring it to your doctor.