Cold Urticaria

1. Do you or your child suffer from Cold Urticaria? *This question is required.

• Yes
• No

2. At what age did symptoms begin? *This question is required.

• Birth - 1 year
• 1-7
• 7-12
• 12-18
• 18-24
• 25-34
• 35-54
• 55+

3. Sex *This question is required.

• Male
• Female

4. Do you have any relatives with Cold Urticaria? *This question is required.

• Yes
• No

9. Do you have or have you had any of the following? *This question is required.

• Rheumatic Fever / Chorea
• Congenital heart lesion / Cardiac pacemaker
• Heart Attack / Angina
• Diabetes - Low blood sugar
• High blood pressure
• Low blood pressure
• Jaundice, hepatitis, or liver disease
• Asthma or hay fever
• Epilepsy
• N/A

10. Do you have sensitive skin? *This question is required.

• Yes
• No

12. Do you have any other types of Urticaria? *This question is required.

• Yes
• No

13. Do you have eczema?

• Yes
• No

14. Do you carry an Epi Pen? *This question is required.

• Yes
• No

16. Has a change in diet help with reactions? *This question is required.

• Yes
• No

17. Have you tried the "Cold Shock Treatement" ? *This question is required.

• Yes
• No

18. Can you consume frozen food or beverages? *This question is required.

• Yes
• No

19. Are you able to swim in lakes, oceans or large bodies of water? *This question is required.

• Yes
• No