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Patient History Template for Paediatric Food Allergy Patient Name: 1. Is there a personal history of allergic problems?  Yes

 No

Details: _______________________________________

2. Is there a family history of allergic problems?  Yes

 No

Details: _______________________________________

3. What was the age of onset and relation to change in diet? Answer: __________________________________________________________ 4. What food or foods are causing concern?    

Cow’s milk Fish Egg Shellfish

   

Peanuts Soya Tree nuts Wheat

Other: ___________________________________________________________ 5. What symptoms are triggered? Skin? Gastrointestinal? Respiratory System? Cardiovascular?

_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

6. What is the time course between exposure and the onset of symptoms?  More than 2 hours

 Less than 2 hours

7. What quantity of food is needed to trigger a reaction? Answer: __________________________________________________________

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Please note that this form is a guide only and not an official test order form.

eAllergy Helpdesk