Date:
Patient:
MRN:
Clinician: (Allergist, Pediatrician)
Reason for Visit:
Follow-up for food allergy
Evaluation of recent allergic reactions (if applicable)
Review of current management plan
Medication refill or adjustment
History of Present Illness:
Briefly describe the details of the patient’s food allergy:
Specific food(s) causing the allergic reaction
Typical symptoms experienced during allergic reactions (anaphylaxis, skin rash, gastrointestinal upset)
Frequency and severity of recent allergic reactions (if applicable)
Dietary restrictions and adherence to an elimination diet (if applicable)
Past Medical History:
Age at first diagnosis of food allergy
History of previous allergic reactions (anaphylaxis, allergic rhinitis, eczema)
Other medical conditions (e.g., asthma)
Family History:
Family history of allergies or atopy (hereditary predisposition)
Social History:
Exposure to potential allergens in daycare, school, or social settings
Discussion about access to safe food options and potential challenges
Physical Exam:
Vital Signs: (may be normal unless presenting with acute allergic reaction)
Skin: Evidence of eczema or other allergic skin manifestations (if applicable)
Labs (limited role in diagnosis):
Skin prick testing or blood tests (specific IgE) may have been performed previously to confirm food allergies. However, these are not included in a typical follow-up visit.
Assessment:
Confirm the diagnosis of food allergy based on history of symptoms and previous testing (if performed).
Evaluate the severity of the allergy based on the type and severity of reactions.
Assess the effectiveness of the current management plan (dietary restrictions, emergency medications).
Plan:
Outline the management plan based on the assessment:
Dietary education: Reinforce the importance of strict avoidance of the trigger food(s).
Emergency medication: Discuss the use of epinephrine auto-injectors (EpiPen) for anaphylaxis and proper administration techniques.
Referral: Consider referral to a dietician for personalized meal planning or to an allergist for complex cases.
Action plan: Develop a plan for accidental allergen exposure and management strategies.
Education:
Document any education provided to the patient and/or caregiver regarding:
The nature of food allergies and the specific allergen(s) to avoid
Safe food handling practices and potential hidden allergens in processed foods
The proper use of epinephrine auto-injectors and recognizing signs of anaphylaxis
The importance of communication with schools, daycare centers, or caregivers about the allergy
Notes:
Include any additional relevant information not covered above, such as the patient’s anxiety level or any specific concerns they may have about managing the allergy.
Consider mentioning the importance of ongoing communication and potential need to adjust the management plan as needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with an allergist or pediatrician for diagnosis, treatment recommendations, and food allergy management strategies.