Self Diagnosis of Allergic Rhinitis Form SELF DIAGNOSIS OF ALLERGIC RHINITIS First Name: Last Name: Address: Age: Please enter a valid age (1-120). Sex: Select Male Female Other Mobile No.: Invalid phone number Diagnostic Criteria (Allergic Rhinitis & its Impact on Asthma) Symptoms: (Presence of any two or more) Yes No Sneezing / छींकें आना Itchy nose / नाक में खुजली Itchy Palate / तालू में खुजली Rhinorrhea / नाक से पानी बहना Nasal congestion / नाक बंद होना Conjunctival hyperemia / आँखों में लालिमा का होना Watering of eyes / आँखों से पानी आना Classification of AR (ARIA) / ए.आर. का वर्गीकरण: Intermittent AR / रुक-रुक कर होने वाला ए.आर. eee Yes No < 4 days per week / < 4 दिन प्रति सप्ताह < 4 consecutive weeks / < 4 लगातार सप्ताह Persistent AR / लगातार रहने वाला ए.आर. spaceeee Yes No ≥ 4 days per week / ≥ 4 दिन प्रति सप्ताह ≥ 4 consecutive weeks / ≥ 4 लगातार सप्ताह Category of AR (ARIA) / ए.आर. (एआरआईए) की श्रेणी: Characteristic Mild Moderate (Any one) Severe (2 or more) Sleep Normal Disturbed Disturbed Daily activities, Sports, Recreation No Impairment Impaired Impaired School or work Normal Disturbed Disturbed Troublesome symptoms Absent Present Present Confirmation of Diagnosis: Yes No Classification: Intermittent Persistent Category: Mild Moderate Severe Submit Form submitted successfully!
