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  Diabetes and Allergy Survey
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

  1. Your first name (No full name please)

  2. Date of birth     Age

  3. Sex: Male     Female

  4. The age at which your diabetes was diagnosed

  5. 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

  6. 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
    spacer
    Mother   Is she type 1 diabetic? Yes     No
    spacer
    Brother(s)   Is he type 1 diabetic? Yes     No
       Is he type 1 diabetic? Yes     No
       Is he type 1 diabetic? Yes     No
    spacer
    Sister(s)   Is she type 1 diabetic? Yes     No
       Is she type 1 diabetic? Yes     No
       Is she type 1 diabetic? Yes     No

  7. If you have nasal congestion, have you tried any decongestant (example, pseudafed or pseudafed containing cold medicine, etc.)? Yes     No

  8. 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

  9. 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


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Last Updated: Thu Aug 29 20:59:46 2002
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