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تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Latex allergy diagnostic questionnaire

Latex allergy diagnostic questionnaire
Circle "Yes" or "No"
Risk factor assessment:
Exposure history:
Are you a health care worker? Yes No
Do you wear latex gloves regularly or are you otherwise exposed to latex regularly? Yes No
Do you have a history of eczema or other rashes on your hands? Yes No
Do you have a medical history of frequent surgeries or invasive medical procedures? Yes No
Did these take place when you were an infant? Yes No
Do you have a history of "hay fever" or other common allergies? Yes No
Do your fellow workers wear latex gloves regularly? Yes No
Do you take a beta-blocker medication? Yes No
Circle any foods below that cause hives, itching of the lips or throat, or more severe symptoms when you eat or handle them:
Avocado Apple Pear Celery Carrot Hazelnut
Kiwi Papaya Pineapple Peach Cherry Plum
Apricot Banana Melon Chestnut Nectarine Grape
Fig Passion fruit Tomatoes Potatoes    
Contact dermatitis assessment (for patients who wear latex gloves frequently):
Do you have rash, itching, cracking, chapping, scaling, or weeping of the skin from latex glove use? Yes No
Have these symptoms recently changed or worsened? Yes No
Have you used different brands of latex gloves? Yes No
If so, have your symptoms persisted? Yes No
Have you used nonlatex gloves? Yes No
If so, have you had the same or similar symptoms as with latex gloves? Yes No
Do these symptoms persist when you stop wearing all gloves? Yes No
Contact urticaria (hives) assessment (for patients who wear latex gloves frequently):
When you wear or are around others wearing latex gloves, do you get hives; red, itchy swollen hands within 30 minutes; or "water blisters" on your hands within one day? Yes No
Aerosol reaction assessment:
When you wear or are around others wearing latex gloves, have you noted:
Itchy, red eyes, fits of sneezing, runny or stuffy nose, itching of the nose or palate? Yes No
Shortness of breath, wheezing, chest tightness, or difficulty breathing? Yes No
Other acute reactions, including generalized or severe swelling or shock Yes No
History of reactions suggestive of latex allergy:
Do you have a history of anaphylaxis or of intraoperative shock? Yes No
Have you had itching, swelling, or other symptoms following dental, rectal, or pelvic exams? Yes No
Have you experienced swelling or difficulty breathing after blowing up a balloon? Yes No
Do condoms, diaphragms, or latex sexual aids cause itching or swelling? Yes No
Do rubber handles, rubber bands or elastic bands, or clothing cause any discomfort? Yes No
Source: American College of Allergy, Asthma and Immunology. Sussman G, Gold M. Guidelines for the management of latex allergies and safe latex use in health care facilities, 1996. www.acaai.org. Reproduced with permission.
Graphic 63643 Version 6.0

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