Please answer the following questions if you are a Type 1 diabetes patient. Thank you, Shih-Wen Huang, M.D. Division of Immunology & Infectious Diseases Deparment of Pediatrics, Box 100296 University of Florida College of Medicine Gainesville, Florida 32610 Diabetes and Allergy Survey Your first name (No full name please) Date of birth Age Sex: Male Female The age at which your diabetes was diagnosed Please check if your doctor said that you have the following conditions: A. Asthma B. Allergic rhinitis (hay fever) C. Food allergy D. Eczema E. Drug allergy F. Hives G. Insect sting allergy H. Latex allergy I. Anaphylaxis Who else in your family (list all) has asthma or allergy? (Please use the code numbers listed above; for example, father has A and B if has asthma and allergic rhinitis) Father Is he type 1 diabetic? Yes No Mother Is she type 1 diabetic? Yes No Brother(s) Is he type 1 diabetic? Yes No Is he type 1 diabetic? Yes No Is he type 1 diabetic? Yes No Sister(s) Is she type 1 diabetic? Yes No Is she type 1 diabetic? Yes No Is she type 1 diabetic? Yes No If you have nasal congestion, have you tried any decongestant (example, pseudafed or pseudafed containing cold medicine, etc.)? Yes No If answer of 7 is yes, did the medicine you had taken for the cold have an effect on your blood sugar level? Yes No If yes, the blood sugar went higher lower If you have asthma and currently under daily medication, please answer the following: Name of the medications Has any medication caused a change in your blood sugar? Yes No If yes, the blood sugar went higher lower Posted 18 March 2000 Survey closed 15 May 2000
Thank you,
Shih-Wen Huang, M.D. Division of Immunology & Infectious Diseases Deparment of Pediatrics, Box 100296 University of Florida College of Medicine Gainesville, Florida 32610
A. Asthma B. Allergic rhinitis (hay fever) C. Food allergy D. Eczema E. Drug allergy F. Hives G. Insect sting allergy H. Latex allergy I. Anaphylaxis
Name of the medications
Has any medication caused a change in your blood sugar? Yes No If yes, the blood sugar went higher lower
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