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: _______________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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