Allergy and Immunology New Patient Consultation Note

Date of Service: [Date of service]

Clinician: [Clinician name and credentials]

Referring Clinician: [Referring clinician name and specialty]

Consult Question: [Consult question verbatim when available]

History Source: [History source] (Specify patient, parent/guardian, interpreter use with language, and any reliability concerns)

Records Reviewed: [Records reviewed]

Reason for Consultation

[Brief synopsis including chief concern in patient's words when diagnostically helpful, goal of consultation, and immediate safety status if relevant] (2–4 lines; this is a synopsis, not the full HPI.)

History of Present Illness

[Narrative summary of current issue including onset, course, exposures of concern, current avoidance or tolerance, and impact on daily life]

Reaction Episodes: (Document each distinct episode separately. Use explicit uncertainty language such as "timing unknown" or "dose not recalled" rather than omitting unknown fields.)

• [Episode date or context]:
  • Suspected trigger: [Specific agent, brand/generic, food form if applicable, cross-contact considerations]
  • Exposure: [Route and approximate amount]
  • Timing: [Onset after exposure, time to peak severity, total duration, biphasic course if any]
  • Symptoms: [Symptoms by organ system—skin, respiratory, GI, cardiovascular, ENT/oral, neurologic—with distribution and progression]
  • Objective findings: [Vitals, oxygenation, clinician-observed signs, photos if referenced]
  • Treatment and response: [Antihistamines, steroids, epinephrine with dose/route, bronchodilators, ED/EMS care]
  • Severity markers: [Syncope, hypotension, hypoxia, respiratory distress, hospitalization/ICU]
  • Reproducibility: [Prior tolerance, subsequent exposures and outcomes]
  • Cofactors: [Exercise, alcohol, NSAIDs, infection, heat, menstruation, fasting]

Current Avoidance and Impact: [Current avoidance behaviors, feasibility, and impact on nutrition, growth, social activities, or quality of life]

(Include differential cues for non-IgE mechanisms, intolerance, or anxiety when present; clearly label as suspected.)

Atopic and Allergic Comorbidities

(Include only conditions present; omit negatives.)

• [Condition]: [Control status]; [Recent exacerbations]; [Current regimen and adherence]; [Relevant triggers]

Prior Allergy Testing and Procedures

(Include dates and locations when known. Distinguish record-confirmed from patient-reported results.)

• Record-confirmed:
  • [Test type, date, location, key results and interpretation]
• Patient-reported (unverified): [Summary of reported prior testing and outcomes]

Treatments to Date

• Avoidance strategies: [Strategies attempted and feasibility]
• Medications: [Name, dose, schedule, duration, response, adverse effects]
• Prior immunotherapy: [SCIT/SLIT/VIT indication, duration, systemic reactions, reason for discontinuation if applicable]
• Biologics/immunomodulators: [Agent, indication, duration, response, adverse effects]

Current Medications

• Antihistamines: [Agent, dose, schedule; timing of last dose if skin testing planned]
• Beta-blockers/ACE inhibitors: [Agent and dose]
• Asthma controllers: [ICS/LABA/LAMA/leukotriene modifier with doses and adherence]
• Systemic steroids/immunosuppressants: [Agent, dose, duration]
• Other medications: [Other relevant current medications]

Allergy and Adverse Reaction List

(For each entry: agent [generic preferred], reaction phenotype, timing pattern [immediate / delayed], approximate date, confirmation status [confirmed / unverified / delabeled with date and basis]. Use "unable to ascertain" when appropriate.)

• Drug Allergies:
  • [Agent]: [Phenotype]; [Immediate / Delayed]; [Date]; [Confirmed / Unverified / Delabeled]
• Food Allergies:
  • [Agent/form]: [Phenotype]; [Immediate / Delayed]; [Date]; [Confirmed / Unverified / Delabeled]
• Venom:
  • [Insect]: [Phenotype]; [Immediate / Delayed]; [Date]; [Confirmed / Unverified / Delabeled]
• Latex: [Phenotype]; [Immediate / Delayed]; [Date]; [Confirmed / Unverified / Delabeled]
• Vaccine Reactions: [Vaccine]; [Phenotype]; [Timing]; [Confirmed / Unverified]
• Other: [Agent]; [Phenotype]; [Timing]; [Status]

Past Medical History

• [Asthma severity/control and exacerbation history]
• [Cardiovascular disease]
• [Mast cell disorders/mastocytosis or baseline tryptase]
• [Autoimmune disease]
• [Chronic urticaria/angioedema]
• [Pregnancy status if applicable]
• [Relevant surgeries]

Family History

• [Atopy/allergic rhinitis/asthma]
• [Food allergy/anaphylaxis]
• [Hereditary angioedema]
• [Primary immunodeficiency]
• [Mastocytosis/mast cell disorders]

Social and Environmental History

• Home environment: [Pets, pests, carpeting, mold/humidity, smoking/vaping exposures, bedding]
• Occupational/school exposures: [Chemicals, animals, foods, latex, other allergens]
• Dietary patterns: [Relevant food exposures/avoidances, cultural considerations]
• Outdoor/travel exposures: [Sting risk, regional allergens, recent travel]

Review of Systems

(Targeted to support the consult question. Always include respiratory and cardiovascular symptoms when anaphylaxis is a concern.)

• Constitutional: [Relevant constitutional symptoms]
• HEENT: [Nasal/ocular/ear/throat symptoms]
• Respiratory: [Wheeze, cough, dyspnea, chest tightness, nocturnal symptoms, exercise limitation]
• Cardiovascular: [Chest pain, palpitations, syncope/presyncope]
• Gastrointestinal: [Nausea, vomiting, abdominal pain, diarrhea]
• Skin: [Rash, urticaria, angioedema, pruritus]

Physical Examination

• Vitals: [Vital signs] (Include height, weight, BMI percentile for pediatric patients)
• General: [Appearance, acute distress assessment]
• HEENT: [Nasal mucosa, turbinate size, polyps, septal findings, postnasal drip, oropharynx]
• Lungs: [Work of breathing, wheeze/rales/rhonchi, air movement]
• Cardiovascular: [Rate/rhythm, perfusion]
• Skin: [Eczema distribution/morphology, urticaria, dermatographism, angioedema, contact patterns]

In-Office Testing Results

(Include only if testing was performed at today's visit.)

• Skin testing: [Site, device type, read time, negative and positive control results, allergen panel with wheal/flare sizes and positivity interpretation, adverse reactions and treatments]
• Spirometry: [Pre/post values, interpretation, clinical correlation]
• Observed challenge or desensitization: [Risk stratification, consent, protocol, dosing and timing, symptoms and interventions, outcome, disposition]

Assessment

(Problem-oriented list ordered by risk/acuity. Do not label anaphylaxis based solely on epinephrine use—document criteria-relevant symptoms and timing. Do not label drug allergies as confirmed without phenotype, timing, and confirmation. Use "adverse reaction—mechanism undetermined" when unclear.)

• [Problem]: [Working diagnosis] ([confirmed / suspected / ruled out])
  • [Supporting evidence and key negatives]
  • [Differential diagnosis if mechanism uncertain]

Plan

(Organize by problem with actionable items.)

• [Problem]:
  • Risk Mitigation: [Epinephrine autoinjector prescription and training, emergency action plan, avoidance guidance, asthma optimization]
  • Diagnostic Plan: [Testing ordered, clinical question addressed, staged approach as appropriate]
  • Therapeutic Plan: [Medications with dose/frequency, non-pharmacologic strategies, immunotherapy candidacy, delabeling approach, safe alternatives]
  • Education: [Counseling topics, device training, patient preferences, written materials provided]
  • Follow-up: [Interval and purpose, return precautions]

Care Coordination

• [Communication to referring clinician with key recommendations]
• [School/work documentation needs]
• [Referrals placed]