Food Allergy Assessment Note - English

**ID:** [Patient identifier] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **RFC:** [Reason for consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Ref MD:** [Referring medical practitioner] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **PMHx:** [Past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Atopic Hx:** Asthma (Most recent PFT: FEV1 [value and units], FVC [value and units], ratio [percentage]) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Allergic rhinitis: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Eczema / Urticaria: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Medication: [atopic-related medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Undergoing allergy immunotherapy: [yes/no and details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **FHx Atopy:** [Family history of atopic disease] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Social:** Occupation: [occupation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Home environment: [home environment details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Habits:** Smoking: [smoking history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) EtOH: [alcohol intake] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Drugs: [recreational drug use] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Meds:** [Current medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Has private insurance: [yes/no] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **HPI:** Details of food reaction symptoms: [symptom description] Food ingredients ingested, quantity and preparation: [details] Associated symptoms: [details] Timing of onset/resolution of symptoms: [details] Medications required: [details] Frequency of symptoms associated with ingestion and consistency of manifestations: [details] (Only include information explicitly mentioned in the transcript, contextual notes or clinical note; omit any element not mentioned.) Cofactors: NSAID use: [details] Exercise: [details] Stress: [details] EtOH: [details] Fever: [details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any cofactor not mentioned.) Food diary: [Food diary information] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **O/E: deferred** General: [general examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Chest: [respiratory examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Skin: [skin examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Skin prick testing:** Inhalants: Positive for: [positive inhalant allergens] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Negative for: [negative inhalant allergens] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Foods: Positive for: [positive food allergens] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Negative for: [negative food allergens] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Other Ix ** [Other investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Diagnosis** IgE mediated hypersensitivity reaction to [allergen] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Pollen-food allergy to [trigger] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Plan:** **Anaphylaxis** – Patient educated on allergen avoidance and instructed on anaphylaxis recognition and management. Instructed on how to use an Epipen and to carry at least one at all times, preferably two. Can use second generation non-sedating antihistamines alongside for additional symptom relief. Written action plan provided. Printed resources provided to patient. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Pollen food allergy syndrome:** avoid culprit fruits and vegetables in their raw state; consumption in cooked state as tolerated. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **MedicAlert bracelet** application made. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Food ladder** discussed today. [Food ladder details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) **Follow up in** [Follow-up timeframe] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)