Allergy Treatment Intake

About You

Please answer as completely as you can. There are no wrong answers — if you're unsure, just tell us what you know.

First name

Last name

Preferred name (optional)

Date of birth

Patients must be at least 5 years old.

Sex listed on your medical records

FemaleMaleOtherPrefer not to say

Phone

Email

Best way and time to reach you (optional)

In a few sentences, what brings you in, and what would you most like us to know? (optional)

Your Allergy Symptoms

Your Triggers & Exposures

Have you ever had allergy testing (skin or blood)? If so, what did it show, and roughly when? (optional)

Do you have pets in the home? (Type and how many) (optional)

Is your home carpeted? Any known mold, dampness, or smoking in the home? (optional)

What do you do for work, and are you exposed to anything there that seems to trigger symptoms (dust, animals, chemicals, being outdoors, etc.)? (optional)

What You've Tried

Which allergy treatments or medications have you tried? (optional)

Check all that apply.

Antihistamine pills (e.g., Zyrtec, Claritin, Allegra, Benadryl)Nasal sprays (e.g., Flonase, Nasacort, Astelin)Eye dropsDecongestants (e.g., Sudafed)Allergy shots (immunotherapy)Other

Names and doses, if you know them (optional)

Which of these helped? (optional)

Which didn't help, or caused side effects? (optional)

Are you currently taking anything for your allergies right now? (optional)

Current Medications & Drug Allergies

List all medications, supplements, and vitamins you take regularly (name and dose if known) (optional)

Do you have any drug allergies? (optional)

No known drug allergiesYes

Health & Safety Screening

These questions help us confirm that sublingual immunotherapy is safe for you. Please answer honestly — some of these don't rule out treatment on their own, but they do change how we approach your care.

Your Life & Goals

This is where we get to know you as a person — it helps us set goals that actually matter to you.

What do you love to do? (Hobbies, sports, time outdoors, pets, travel, etc.) (optional)

What are your allergies keeping you from doing? (optional)

What would success look like for you? If treatment works well, what do you most want to be able to do again — or do more of? (optional)

Allergy Testing

Treatment starts with an IgE environmental allergy panel. How would you like to complete yours?

Choose a testing option

In person at our Traverse City, MI clinicTest kit mailed to meI have a recent IgE allergy panel (within the last year) to upload

Start your allergy treatment journey