Item | Options | Score | Total score |
---|---|---|---|
Q1. In the past 12Â months, have you had a problem apart from cold or flu with: Sneezing? Runny nose? Blocked nose? | â–¡ No â–¡ Yes | Min 0, Max 3; 1 per symptom | 3 |
If ‘NO’ do not respond to the following questions | |||
 Q2. In the past 12 months has this nose problem been accompanied by itchy/watery eyes? | □ No □ Yes | Min 0, Max 2; YES = 2 | 5 |
 Q3. In which of the past 12 months (or in which season) did this nose problem occur? | □ Jan □ Feb □ Mar □ Apr □ May □ Jun □ Jul □ Aug □ Sep □ Oct □ Nov □ Dec | Min 0, Max 2; 1 if ≥ 7 months; 1 for pollen seasona | 7 |
 Q4. In the past 12 months has your nose problem disturbed your daily activity? | □ Never □ Sometimes □ Rarely □ Often | n/a | 7 |
 Q5. What trigger factors provoke or increase your nose problem? | □ No □ Yes | Min 0, Max 2; Yes to epithelia (animals) OR moulds only = 1; Yes to pollens or dust = 2; Yes to pollens or dust + epithelia or moulds = 2 | 9 |
House dust/dust mites? Pollens? Animals (cats, dogs etc.) Others? | â–¡ No â–¡ Yes â–¡ No â–¡ Yes â–¡ No â–¡ Yes | ||
 Q6. Do you think you are allergic? | □ No □ Yes | Min 0, Max 2; YES = 2 | 11 |
 Q7. Have you already been tested for allergy (SPT, IgE etc.)? | □ No □ Yes | Min 0, Max 2; Both YES = 2 | 13 |
If yes, was it positive? | â–¡ No â–¡ Yes | ||
 Q8. Has a doctor already diagnosed that you suffer/suffered from an allergy (asthma, eczema, AR)? | □ No □ Yes | Min 0, Max 1; YES = 1 | 14 |
 Q9. Do you think you are asthmatic? | □ No □ Yes | n/a | 14 |
 Q10. Does any member of your family suffer from asthma, eczema or AR? | □ Father □ Mother □ Sibling | Min 0, Max 2; ≥1 specified family member suffering from one allergy = 2 | 16 |