Were you referred by one of our paediatric allergy specialists?
YesNo
Please specify the name of the clinician who referred you
Parent/Guardian Name
Child’s Full Name
Child's DOB
Child Age
Email address
Telephone number
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Choose as many as you like
AlmondBrazil NutCashewCows' MilkEggHazelnutMacadamiaPeanutPecanPistachioSesameSoyaWalnutWheatOther
If 'Other' is selected, please specify:
Please include details of allergy tests (including dates) and previous reactions. If there is uncertainty, this will be discussed at an assessment visit and if required, further testing or food challenges can be arranged.
Allergen Allergen Allergen
Recent Skin Prick test (& when) Recent Skin Prick test (& when) Recent Skin Prick test (& when)
Recent IgE blood test (& when) Recent IgE blood test (& when) Recent IgE blood test (& when)
History of reaction History of reaction History of reaction
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Has your child ever had an allergic reaction (to food in question or other food) either requiring admission to an intensive care unit or requiring more than 2 injections of adrenaline?
If yes, please provide details:
Has your child ever reacted to trace exposure?
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YesNoUnsure
If yes, or unsure, please provide further details such as current regular medication, any previous hospital visits, who is monitoring the asthma, details of any hospital visits that required intensive care or intravenous medication as well as current asthma control/Ventolin usage:
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If yes, please provide details including diagnosis, where this was managed, what medication was required and current disease status:
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If yes, please provide details including diagnosis, where this is being managed, what medication was required and current disease status:
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Medication Medication Medication Medication Medication Medication
Dose Dose Dose Dose Dose Dose
How often (e.g. once daily) How often (e.g. once daily) How often (e.g. once daily) How often (e.g. once daily) How often (e.g. once daily) How often (e.g. once daily)
Why taken Why taken Why taken Why taken Why taken Why taken
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For AAI (eg Epipen, Jext), how many devices For AAI (eg Epipen, Jext), how many devices For AAI (eg Epipen, Jext), how many devices For AAI (eg Epipen, Jext), how many devices For AAI (eg Epipen, Jext), how many devices For AAI (eg Epipen, Jext), how many devices
When were you last trained to use these When were you last trained to use these When were you last trained to use these When were you last trained to use these When were you last trained to use these When were you last trained to use these
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