Food Allergy Evaluation Note

Date/Time: [Encounter date and time]

Location: [Clinic location]

Referral Source: [Referring clinician / self-referred]

Historian: [Patient / parent / caregiver with name and relationship]

Records Reviewed: [ED notes / EMS records / photos / prior allergy testing / other relevant records]

Interpreter: [Language and modality] (Only include if interpreter was used.)

Allergy List Reconciliation: [Verification steps and updates made; note discrepancies between chart and current history and how resolved]

Chief Concern

[Reason for consultation in 1–2 lines] (State primary concern first if multiple foods involved.)

History of Present Illness

[Brief narrative summary of presenting problem] (Attribute information to source: patient reports, parent reports, or records indicate.)

Index reaction

• Suspected food(s) and form: [Food(s) and form (raw/cooked/baked); brand or restaurant if relevant]
• Date and setting: [Date/timeframe and location]
• Portion and exposure context: [Portion size; new vs routine food; cross-contact concerns]
• Onset timing: [Time from ingestion to symptom onset]
• Symptoms by organ system: Cutaneous: [findings or none]; Respiratory: [findings or none]; Gastrointestinal: [findings or none]; Cardiovascular/Neurologic: [findings or none]
• Severity markers: [Epinephrine given with doses and timing / oxygen / IV fluids / hospitalization / ICU / biphasic course]
• Treatment and response: [Therapies given and clinical response]
• Duration to baseline: [Time to resolution]
• Unknown elements affecting risk assessment: [Key unknowns] (Explicitly document if crucial details are unknown.)

Reproducibility and threshold

• Prior similar reactions: [Yes/No; number and context]
• Ability to ingest without symptoms: [Never / sometimes / routinely; specify forms tolerated]
• Smallest known amount causing symptoms: [Threshold amount if known]
• Accidental exposures without reaction: [Yes/No; context]

Cofactors around time of reaction

• Exercise: [Before/after ingestion / none]
• Alcohol, NSAIDs/aspirin: [Present / absent]
• Intercurrent illness/fever: [Present / absent]
• Asthma control at time: [Well controlled / partially controlled / uncontrolled]
• Pattern suggesting FDEIA: [Suggestive / not suggestive] (Comment on timing and repeatability if relevant.)

Differential considerations (Include only if suggested by history.)

• [Viral illness temporally related / food poisoning pattern / isolated oral symptoms consistent with pollen-food allergy syndrome / delayed reactions to mammalian meat suggesting alpha-gal syndrome / other alternative diagnoses]

Diet and Tolerance History

• Foods routinely eaten without reaction: [List; include broader food family]
• Foods currently avoided and reason: [Food: prior reaction / positive test / precautionary]
• Tolerance of suspected foods: [Last known ingestion without symptoms; tolerance of baked/heated forms; tolerance of related foods]
• Cross-contact experiences: [Exposures and outcomes]
• Nutritional risk screening: [Growth concerns / restricted protein or calcium sources / none; dietitian referral offered/accepted/declined if indicated]

Relevant History

• Atopic comorbidities: Asthma: [control status, recent exacerbations, controller adherence]; Atopic dermatitis: [severity]; Allergic rhinitis: [present/absent, control]; Prior anaphylaxis to any trigger: [details]; Eosinophilic GI disease: [present/absent]
• Medications affecting testing or anaphylaxis risk: [Antihistamines with timing; beta-blockers; ACE inhibitors]
• Pertinent family history: [Include only if relevant to food allergy risk]
• Social/environmental factors: [School/work exposure risks; ability to self-carry epinephrine; access to emergency services; dining-out frequency]

Physical Examination

Vitals: [Vital signs if obtained]

[Focused examination findings relevant to presentation, typically including skin, respiratory, and HEENT] (Document absence of findings only when it supports clinical assessment.)

Allergy Testing

Skin prick testing (SPT) (Include only if performed today.)

• Indication and targeted allergens: [Targets based on history] (Avoid indiscriminate panels.)
• Controls: Positive: [result mm]; Negative: [result mm]
• Results (wheal, mm): [Allergen – size for each tested]
• Validity: [Controls appropriate / not appropriate]
• Adverse events: [None / details]
• Interpretation: [Clinical correlation] (State explicitly that positive SPT indicates sensitization and requires correlation with history.)

Serum specific IgE (sIgE/component testing) (Include if reviewed or ordered.)

• Date and source: [Lab/date]
• Results: [Allergen/component – value, units]
• Interpretation: [Interpretation anchored to pretest probability] (State limitations: positive supports sensitization but not necessarily clinical reactivity; negative does not exclude allergy if history is compelling; test magnitude does not predict severity.)

Oral food challenge (OFC) (Include if completed, reviewed, or planned.)

• Status: [Completed today / prior challenge reviewed / planned / deferred]
• Clinical question and rationale: [What the challenge will answer; why indicated now or reason for deferral]
• Outcome: [Tolerance / objective symptoms and criteria for stopping / treatment given] (Include if completed.)

Non-IgE–mediated considerations (e.g., FPIES) (Include if suspected.)

• Timing pattern: [Delayed vomiting 1–4 hours post-ingestion; lethargy; pallor]
• Absence of IgE features: [No hives/wheeze]
• Reproducibility and ED/IV fluid needs: [Details]

Assessment

(Use problem-oriented format. Do not infer anaphylaxis unless criteria are met; use "possible anaphylaxis" when uncertain. Base risk on clinical history rather than test magnitude. Explicitly state that test results do not predict reaction severity.)

[Food/Trigger 1]: [Working diagnosis]

• Certainty: [Confirmed / probable / possible / unlikely]
• Phenotype: [IgE-mediated immediate reaction / delayed or non-IgE pattern / unclear]
• Risk stratification (history-based): [Prior systemic reaction details; asthma control; history of multiple epinephrine doses or biphasic reactions; access barriers]
• Synthesis: [Concise explanation of how history and testing support or do not support diagnosis] (Reiterate that test magnitude does not predict severity when relevant.)

[Food/Trigger 2]: [Working diagnosis]

(Repeat structure for each additional suspected food.)

Plan

[Food/Trigger 1]

• Diagnostic plan: [Targeted testing; additional records needed; OFC indicated now vs deferred with rationale; interim diet guidance specifying what to avoid and what is explicitly allowed]
• Avoidance counseling: [Label reading; cross-contact mitigation; restaurant communication; school/work accommodations; specific foods and forms to avoid vs permitted]
• Emergency preparedness:
  • Epinephrine autoinjector: [Prescribed / already has / not prescribed; number of devices and dose]
  • Training and teach-back: [Completed / not completed; patient understanding documented]
  • Written anaphylaxis action plan: [Provided / reviewed / not provided]
  • When to use epinephrine and seek emergency care: [Instructions reviewed]
  • Medical identification: [Recommended / not recommended / declined]
  (Document these elements even if not done, with rationale.)
• Referrals and support: [Dietitian if nutritional risk; resources for anxiety/quality-of-life as relevant]
• Follow-up: [Timeline for results review; re-evaluation schedule; how to contact clinic for interim reactions]

[Food/Trigger 2]

(Mirror structure for each additional problem.)

Orders and Communication

• Orders placed today: [Tests, medications, referrals]
• Communication to referring clinician: [Key conclusions and next steps]

(Omit sections with no relevant content rather than leaving empty placeholders, except emergency preparedness elements which should be documented even if not completed, with rationale. Do not state or imply that test magnitude predicts reaction severity. Attribute history to appropriate source.)