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 |