1. QUESTIONNAIRE CANNABIS ALLERGY & FOOD ALLERGY Available in NL-FR-ENG 1 Hello, Thank you for taking part in this study. This questionnaire is part of the research on cannabis allergy performed by the University of Antwerp in collaboration with the University of Ghent. In this questionnaire you will find questions on your (known) allergies, allergic symptoms on contact with different foods and contact with cannabis. We would like to ensure you once more that all information is handled strictly confidential and only visible to the researchers. Processing of data and potential publication of results will be anonymous. 2 Who is filling in this questionnaire? o I, the patient itself o I, parent/guardian of the patient 3 Date of birth (dd/mm/jjjj) ________________________________________________________________ 4 Surname and given name ________________________________________________________________ 5 To keep you informed on your blood results and/or inquire additional information we would like to ask you to write down your contact information (e-mail address/telephone number) below. ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 6 Sex o man o woman 7 Who is your treating physician? Prof. dr. Ebo Prof. dr. Hagendorens ▢ dr. Sabato ▢ dr. Uyttebroek ▢ dr. Faber ▢ dr. Decuyper ▢ dr. Van Gasse ▢ I don't have a treating physician ▢ I don't know ▢ 8 You work as ▢ a police officer/employee laboratory personnel ▢ employee responsible for the evacuation of drugs/cannabis plantations ▢ other ________________________________________________ ▢ 9 Can you describe if and how you are exposed to cannabis through your professional activity? ▢ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 10 Your country of origin is: o Belgium o The Netherlands o I come from another country: ... ________________________________________________ 11 Did you suffer from eczema during your childhood? o Yes o No 12 Do you suffer from asthma (now or did you in the past)? Asthma is characterized by shortness of breath, acute couching episodes and/or wheezing) o Yes o No 13 Do you use any of the medication mentioned below? I do not use any medication Antihistamines (Cetirizine, Desloratadine, Rupatall, Ebastine, …) ▢ Nose spray (for example Nasonex, Avamys, mometasone,…) ▢ Inhaler/aerosols (for example Symbicort, Avamys etc.) ▢ I use other medication (then described above) ▢ 14 Do you use any of the medication/products mentioned below? ▢ Diet pills Nutritional supplements ▢ ▢ Muscle reinforcing medication I do not use any of the above medication ▢ 15. You have indicated using diet pills/muscle reinforcing medication and/or nutritional ▢ supplements. Could you write down the exact name of the products your using below? ________________________________________________________________ 16 Have you ever suffered from allergic signs on contact/eating fruits? (for example peach, apple, citrus, kiwi, cherries, banana etc. ?) o Yes o No o I don't know 17 What allergic sings do you experience on contact with/eating peach? I eat peach without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat peaches and never had an ▢allergic reaction on peaches in the past ▢ Other allergic signs 18 What allergic signs did you experience on contact with apple ? ▢ I eat apples without any allergic signs ▢ Within minutes, I develop signs limited to mouth and throat: itchiness lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalised itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat apples and never had an ▢allergic reaction on apples in the past ▢ Other allergic signs 19 What allergic signs did you experience on contact with citrus fruit (orange, lemon, grape ▢ fruit, …)? I eat citrus fruit without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat citrus fruit and never had an ▢allergic reaction on citrus fruit in the past ▢ Other allergic signs 20 What allergic signs did you experience on contact with kiwi? ▢ I eat kiwi fruit without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalised itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat kiwi fruit and never had an ▢allergic reaction on kiwi fruit in the past ▢ Other allergic signs 21 What allergic signs did you experience on contact with cherries? ▢ I eat cherries without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat cherries and never had an ▢allergic reaction on cherries in the past ▢ Other allergic signs 22. What allergic signs did you experience on contact with banana? ▢ I eat bananas without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat bananas and never had an ▢allergic reaction on bananas in the past ▢ Other allergic signs 23 Have you experienced allergic signs on contact with other fruit then already mentioned ▢ before? o Yes; Which fruits, other than the ones mentioned before also induce allergic signs? ________________________________________________ o No 24 You experience allergic signs on fruit only when they are: o Raw fruit o Cooked/heated/processed fruit o Both raw and cooked/heated/processed fruit 25 Do you, personally, see a link between your allergic signs and physical exercise? (such as running, cycling, running up the stairs, sports,…) o Yes ________________________________________________ o No 26 Have you ever suffered from allergic signs on contact/eating vegetables? (for example carrot, celery, potato, tomato etc. ?) o Yes o No o I don't know 27 What allergic signs did you experience on contact with carrots? I eat carrots without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat carrots and never had an ▢allergic reaction on carrots in the past ▢ Other allergic signs 28 What allergic signs did you experience on contact with potatoes? ▢ I eat potatoes without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat potatoes and never had an ▢allergic reaction on potatoes in the past ▢ Other allergic signs 29 What allergic signs did you experience on contact with celery? ▢ I eat celery without any allergic signs ▢ Within minutes, I develop signs limited to mouth and throat: itchiness lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat celery and never had an ▢allergic reaction on celery in the past ▢ Other allergic signs 30 What allergic signs did you experience on contact with tomatoes? ▢ I eat tomatoes without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat tomatoes and never had an ▢allergic reaction on tomatoes in the past ▢ Other allergic signs 31 Have you experienced allergic signs on contact with other vegetables then already ▢ mentioned before? o Yes. Which vegetables, other than the ones mentioned before, also induce allergic signs? ________________________________________________ o No 32 You experience allergic signs on vegetables only when they are: o Only raw vegetables o Only cooked/heated/processed vegetables o Both raw and cooked/heated/processed vegetables 33 Have you ever suffered from allergic signs on contact/eating legumes? (for example peas, soy, chick peas, lentils, beans, etc. ?) o Yes o No o I don't know whether I experience allergic symptoms on contact with/eating legumes 34 What allergic signs did you experience on contact with peas? I eat peas without any allergic signs Within minutes, I develop signs limited to mouth and throat: itchiness ▢lips/mouth/throat, limited redness around the mouth, swelling lips/tongue ▢ Within minutes, I develop at least two of the following: redness of the skin/ generalized itchiness/ swelling of face/lips/tongue/throat, shortness of breath, vomiting, diarrhea, loss of consciousness ▢ I experience worsening of my atopic eczema Allergic signs are unknown, because I don't eat peas and never had an allergic ▢reaction on peas in the past ▢ Other allergic signs 35 What allergic signs did you experience on contact with soy? ▢ I eat soy (products) without any allergic signs ▢