ABC Pediatrics Allergy Questionnaire

ABC Pediatrics' Allergy Questionnaire

This form must be filled out for new allergy referral patients.
Patient Name

First NameLast Name
Phone Number

Area CodePhone Number
Birth Date

MonthDayYear
Which provider at ABC do you normally request or see?
Does the patient suffer from allergies?
Does the patient take allergy medications?
In the last year, check any of the medications that the patient has taken.
When the patient suffers from allergy symptoms, how is his/her quality of life affected? (Check all that apply)
Has the patient ever had a severe anaphylactic reaction (severe allergic reaction) that required emergency medical attention?
If YES, Please describe what happened:
Has the patient ever been diagnosed as a moderate or severe asthmatic?
Is the patient taking blood pressure medications?
Within the past year, has the patient had an allergy scratch test?
Within the past year, has the patient had immunotherapy medication prepared?
Does the patient have a history of taking allergy medications, including allergy shots?
If yes, please list:
Are you interested in learning more about proceeding with allergy testing?
If you answered yes or maybe, please be expecting a call from us soon!
Parent/Guardian Signature
Do not fill anything else out past this point! The information below is for ABC Pediatrics and your provider's use only.
As the patient’s PCP, I am recommending that my patient proceed with Percutaneous (Skin Prick) Allergy Testing. * In Office Use Only
Primary Care Provider’s Signature- *In Office Use Only
Should be Empty:

ABC Pediatrics' Allergy Questionnaire