The objective of this study was to determine the prevalence of respiratory symptoms and their relationship to sensitization to wheat flour allergens and fungal amylase, in a group of workers from the UK flour milling industry. A cross-sectional study was used to evaluate symptoms, using a structured interview technique, and sensitization, using skin prick test findings, from 679 employees in flour milling and packing operations at 18 flour mills. A total of 147 workers (147/679, 22%) described upper respiratory tract symptoms of some kind. In the majority (139/147, 95%) these symptoms were of an occasional or transitory nature and were related to short-term exposures to high levels of dust. Three individuals (3/679, 0.4%) were identified whose symptoms were thought to be the result of allergy to wheat flour. The prevalence of positive skin prick tests to wheat flour allergens and to fungal amylase was 1.2% (8/678) and 0.9% (6/678), respectively. Measurements of total inhalable dust exposure for personnel exposed to flour dust were taken at 10 of the sites (116 samples). For production personnel the levels were typically between 1 and 10 mg/m3 (8-h time weighted average), with a median of 6.2 mg/m3. Hygiene operatives had appreciably higher exposure than production personnel, with a median of 18.7 mg/m3. Overall, 43% (50/116) of all samples exceeded 10 mg/m3 (8-h time weighted average). The findings suggest that the risk of sensitization to wheat flour allergens from current dust exposures in flour mills is very low. Wheat allergy was responsible in only a small proportion of the total who had respiratory symptoms. The principal causation of symptoms experienced by the workforce was considered to be a non-specific irritant effect related to short-term exposures to high levels of total inhalable dust.