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Allergy Survey

Hello, we are conducting a survey about allergies and would like to invite you to help me fill out this questionnaire in a few minutes. This questionnaire is anonymous. All data is only used for statistical analysis. Please feel free to fill it out. There is no right or wrong target option, please fill in according to your actual situation. thank you for your help.

Your age?

10 years old

11 years old

12 years old

13 years old

14 years old

15 years old

16 years old

Your gender?

Female

Male

Your ethnicity?

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: A person having origins in any of the black racial groups of Africa. Terms such as Haitian or Negro can be used in addition to Black or African American.

Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. The term, Spanish origin, can be used in addition to Hispanic or Latino.

White. A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

Your grade level?

5th

6th

7th

8th

9th

Do you currently or used to have a food allergy? If so, which kind?

Egg

Milk

Fish (e.g., bass, flounder, cod)

Crustacean shellfish (e.g., crab, lobster, shrimp)

Tree nuts (e.g., almonds, walnuts, pecans)

Peanuts

Wheat

Soybeans

I believe I dont have any food allergies

I have been tested and dont have any food allergies

How severe is your allergy?

Light

Moderate

Severe (life threatening)

I dont have an allergy

Does, or has anyone in your family (Blood relatives) ever had or currently have a food allergy? If so, who?

Mother

Father

Grandfather

Grandmother

Older Sister

Younger Sister

Older Brother

Younger Brother

Aunt

Uncle

None

If one or more of your blood relatives have/ had an allergy, what kind of allergy is it?

Egg

Milk

Fish (e.g., bass, flounder, cod)

Crustacean shellfish (e.g., crab, lobster, shrimp)

Tree nuts (e.g., almonds, walnuts, pecans)

Peanuts

Wheat

Soybeans

None of my blood relatives have an allergy

How long have you lived in the U.S.?

1 years

2 years

3 years

4 years

5 years

6 years

6 or more years

Lifetime

Have you lived anywhere outside of the U.S.? If so, where and how long? (If NOT, Answer no.)

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