Oral Food Challenge Procedure Note

Patient Name: [Patient full name]

Date of Birth: [DOB]

MRN: [Medical record number]

Date of Service: [Date]

Clinic Location: [Clinic/facility name]

Performing Clinician: [Clinician name and credentials]

Challenge Details

Food challenged: [Common name] — [Specific form/matrix]
Challenge type: [open / single-blind / double-blind]
Challenge goal: [diagnostic confirmation / tolerance assessment / threshold determination]

(Include this section even if the challenge is cancelled or deferred.)

Indication and Pre-Challenge Assessment

Indication: [Brief narrative of the clinical question and context, including prior reaction history summary and relevant testing results]

Eligibility confirmation:

• [Current health status, explicitly noting presence/absence of acute illness or fever]
• [Asthma status and control level if applicable]
• [Medication review: antihistamines held appropriately with timing; beta-blockers present yes/no; other relevant medications]

Baseline measurements:

• Weight: [kg] (Required for emergency dosing calculations)
• Vital signs: HR [value], BP [value], RR [value], SpO2 [value]
• Focused baseline exam:
• Skin: [Findings with explicit negatives, e.g., no urticaria or angioedema]
• Respiratory: [Findings with explicit negatives]
• Oropharynx: [Findings with explicit negatives]
• GI/Abdomen: [Findings with explicit negatives]

Risk assessment: Overall risk [low / moderate / high]. Specific risk factors: [List factors such as prior anaphylaxis, poorly controlled asthma, or "None identified"]

Consent and Safety Readiness

Informed consent: [Name of consenting individual and relationship to patient]. Consent type: [written / verbal]. Risks, benefits, and alternatives discussed, including risk of anaphylaxis requiring epinephrine. [Pediatric: guardian consent documented; child assent obtained if age-appropriate]

Safety readiness: Emergency medications and equipment available; staff prepared to recognize and treat allergic reactions including anaphylaxis.

Planned Protocol

Protocol type: [Semi-log incremental / linear / institutional protocol name and version]
Target total dose: [Total amount and units]
Planned dose interval: [Minutes between doses]
Stopping criteria: [Objective signs that will halt challenge; approach to subjective symptoms]

Dosing Administration Record

Challenge start time: [HH:MM]
Challenge end time: [HH:MM] (final ingestion or stop time)

Dose #	Time (HH:MM)	Planned amount	Actual amount ingested	Cumulative dose	Deviations and reason
[1]	[HH:MM]	[Amount + units]	[Amount + units]	[Cumulative amount]	[None / description]
[2]	[HH:MM]	[Amount + units]	[Amount + units]	[Cumulative amount]	[None / description]
[Additional rows as needed]

(Use absolute clock times. Note partial ingestion or modifications with reason.)

Monitoring and Symptom Log

[No symptoms observed or reported during dosing and observation period. / Symptom events documented below:]

• Event [#]: Time [HH:MM], [minutes] post-last dose. Organ system: [skin / GI / respiratory / cardiovascular / neurologic]. Findings: [Objective descriptors]. Severity: [mild / moderate / severe]. Anaphylaxis criteria met: [yes / no]. Action: [continued observation / held dosing / treated / stopped challenge].
• (Add additional events as needed)

Vital signs:

Time (HH:MM)	Context	HR	BP	RR	SpO2	Notes
[HH:MM]	[Baseline / Periodic / Symptom onset / Post-treatment / Pre-discharge]	[value]	[value]	[value]	[value]	[Notes]
[Additional rows as needed]

Interventions

(Only include this section if treatment was administered; omit entirely if none needed.)

• Medication: [Name], Dose: [amount + units], Route: [route], Site: [site if IM], Time: [HH:MM], Indication: [triggering symptom/sign], Response: [clinical response]
• Epinephrine details (if given): First dose [HH:MM], total doses [#], response to each dose [describe], rationale for repeat dosing if applicable [reason]
• Non-pharmacologic interventions: [Positioning / supplemental oxygen / IV access / fluids / EMS activation / transfer] at [HH:MM], response [describe]

Outcome and Interpretation

Outcome: [Passed/Negative / Failed/Positive / Inconclusive / Incomplete / Cancelled/Deferred]

Interpretation: [For passed: total dose tolerated and symptom-free observation duration. For failed: objective signs determining failure, threshold dose at reaction, suspected reaction phenotype (IgE-mediated vs. FPIES vs. other). For inconclusive: reason and recommended next steps.]

Anaphylaxis criteria met: [yes / no / not applicable] — [Brief rationale if reaction occurred]

Complications: [None / list]

Disposition and Discharge

Observation: [Duration after final dose or symptom resolution]

Vital signs at discharge: HR [value], BP [value], RR [value], SpO2 [value]

Condition at discharge: [stable / improved / other]

Disposition: [Home / Emergency department / Admission / Other]

Discharge instructions:

• Return precautions: [Signs of recurrent or biphasic reaction; when to use epinephrine; when to call EMS]
• Medications prescribed: [List with dosing instructions, or None]
• Activity restrictions: [Restrictions if applicable, especially after anaphylaxis treatment, or None]

Dietary Guidance and Follow-up Plan

Dietary recommendation: [If passed: when to begin home introduction, recommended frequency, form limitations if any, initial quantity guidance. If failed: continue strict avoidance, cross-contact and label-reading counseling provided, dietitian referral if indicated.]

Emergency preparedness: Epinephrine autoinjector: [new prescription / renewed / confirmed current device]. Technique reviewed: [yes / no]. Anaphylaxis action plan: [provided / updated / not applicable].

Follow-up: [Timeframe for next appointment], [planned repeat testing or future challenges if any], [ongoing management plan if reaction occurred]

(Do not infer outcome or absence of symptoms. Use explicit negative documentation for asymptomatic challenges. For unavailable information use "Unknown" if not obtained, "Not assessed" if not evaluated, or "Not applicable" if item does not apply.)