Patient Medical History - New England Food Allergy Treatment Center
ID#_______ New England Food Allergy Treatment Center Medical History Form Patient Name: _____________________________________Sex:______ D.O.B: ______/______/______ Do you see an allergist? Circle: YES or NO Primary Care Doctor: Name/Address:____________________________ _________________________________________ _________________________________________ Most recent visit:__________________________ Name/Address:___________________________ _______________________________________ _______________________________________ _______________________________________ Allergy History: Please list foods you are allergic to: _____________________________________________________________________________________ Have you/your child ever had an allergic reaction? Circle: YES or NO If yes, to what food/foods? ______________________________________________________________ Please describe reaction/reactions: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Date of reaction/reactions:_______________________________________________________________ Treatment given:_______________________________________________________________________ How much allergen was eaten? ___________________________________________________________ Skin tested to allergen? Circle: YES or NO Date: _______________ Result: ________________ Date of most recent blood test: _________________ Result/if known: __________________________________________ (if not, please contact your doctor) Oral Challenge? Circle: YES or NO Result: _______________________________ Allergic History: (Symptoms, triggers, current treatment, date of onset/diagnosis) All Food Allergies/to what________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Asthma: ______________________________________________________________________________ Allergic Rhinitis: _______________________________________________________________________ Atopic Dermatitis (Eczema): ______________________________________________________________ Drug/Insect Allergy: ____________________________________________________________________ Please circle which medication used: EpiPen / EpiPen Jr. / Auvi-Q / Auvi-Q Jr. Date expires: ________________ (If expired, please ask for a prescription) Significant Medical History: ______________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Family History of allergy (Immediate family members):_________________________________________ _____________________________________________________________________________________ All Current Medications: Medication Dose Indication If asthma history, please describe (onset/treatment/duration): __________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Are symptoms greater than twice a week or continuous? Circle: YES or NO If yes, please describe frequency: _________________________________________________________ _____________________________________________________________________________________ Circle Symptoms: Coughing / Chest Tightness / Wheezing / Shortness of Breath If available, Peak Flow: _______ AM(pm)/_________ PM(pm) Personal best PF: ______ Nighttime symptoms? Circle: Always / During Exacerbations Only / Never Exercise symptoms? Circle: Routine Activities / Vigorous Exercise / None ER visit or hospitalizations in the past 6 months? Please describe: _______________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
© Copyright 2024