Diabetes 123 - Diabetes and Allergy Survey



		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

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

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