Food Allergy Questionnaire

THE UNIVERSITY OF MICHIGAN
DIVISION OF ALLERGY AND CLINICAL IMMUNOLOGY

Food Allergy Service
Visit Questionnaire
NAME: _____________________________________ REGISTRATION #: _______________
REFERRING DOCTOR: __________________________________________________________
ADDRESS OF REFERRING DR: ___________________________________________________
______________________________________________________________________________
1. What problems bring you or your child to an allergist? ________________________________

_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
2. Please place a check mark in front of symptoms you or your child has had in relation to a food
ingestion
( ) Hives ( ) Wheezing ( ) Eczema/atopic dermatitis
( ) Nausea ( ) Vomiting ( ) Diarrhea
( ) Passed out ( ) Shock ( ) Anaphylaxis
( ) Behavior changes ( ) Itching ( ) Other____________
3. Please list the foods that have caused problems for you or your child, and the problem each
food caused:
Foods Problems
___________________________________ _____________________________________
___________________________________ _____________________________________
___________________________________ _____________________________________
___________________________________ _____________________________________
___________________________________ _____________________________________
4. Have you or your child been diagnosed with any other allergic conditions?
( ) Asthma ( ) Eczema
( ) Rhinitis ( ) Urticaria/Angioedema (hives/swelling)
( ) Medication allergies ( ) Food Allergies
( ) Latex allergy ( ) Venom allergy (i.e. Bee, wasp)
5. If your child has asthma, how often do they need a rescue medicine (albuterol)
( ) Less than once a week ( ) Twice a week
( ) Daily ( ) Never
6. Has your child been to the hospital because of asthma?
( ) No ( ) Emergency Room Only
( ) Hospitalized Overnight ( ) Intensive Care Unit
7. Has your child been diagnosed with Eczema?

( ) Yes ( ) No
8. If your child has eczema, which of the following medications has your child needed for
treatment?
( ) Steroid Creams ( ) Oral Steroids
( ) Antibiotics ( ) Antihistamines
( ) Moisturizers ( ) Other crèmes
( ) None ( ) All of the above
9. How were you or your child diagnosed with allergies before?

( ) Skin testing ( ) Blood Testing
Results:_______________________________________
_____________________________________________
Please bring results of prior skin or blood testing to the office visit if available.
10. Do you or your child have any other medical problems?

( ) Lung problems ( ) Heart problems
( ) Kidney problems ( ) Stomach problems
( ) Skin Problems ( ) Behavior problems
( ) Other___________________
11. Have you or your child been hospitalized before?

( ) No
( ) Yes Date Reason
________________ ______________________________________
________________ ______________________________________
________________ ______________________________________
________________ ______________________________________
12. What medications are you or your child taking?

1. _____________________________ 4. _________________________________
2. _____________________________ 5. _________________________________
3. _____________________________ 6. _________________________________
13. Birth History
a. Were there any problems during pregnancy? ( ) N ( ) Y ___________________

b. Were there any problems during delivery? ( ) N ( ) Y ____________________
14. Birth weight ________
a. How was your child fed? (check all that apply)

( ) Breast fed (how many months? ____)
( ) Bottle fed
Which formula (s)? _______________
15. Were there any problems tolerating formulas? _______________________
16. How old was your child when solid food was introduced? ______________
FAMILY HISTORY
1. Do other people in your family have any of the following conditions?

( ) Food Allergies ( ) Eczema ( ) Asthma
( ) Hay Fever ( ) Drug allergies
2. Are there any other medical problems in your family (please specify)?
( ) Heart disease ( ) Lung problems
( ) Skin problems ( ) Stomach problems
( ) Other_____________________________________________________________________
ENVIRONMENTAL HISTORY:
Residence: Age ___yrs. How long have you lived there? _______
Basement: ( ) Y ( ) N Obvious mold or mildew? ____________
( ) City ( ) Suburb ( ) Rural
Pets: ______________
SOCIAL HISTORY
1. Who lives at home? ____________________________________________________________
2. During the day, your child is: ( ) At home ( ) In day care

( ) At school ( ) At relative’s house
3. Are you, your child or your family worried about food allergies? ( ) Y ( )N
4. Since the diagnosis of food allergy, have you or your child have any increase in tears,
sleeplessness, sadness, mood swings or worry? ( ) Y ( )N
5. Since the diagnosis has tension increased in the home?
( ) Not at all ( ) Moderately ( ) Significantly
6. Has your child been the target of teasing or aggressive behavior due to the diagnosis?
( )Y ( )N
7. In the 6 months since diagnosis, do you believe your anxiety related to the allergy has
increased?
( ) None ( ) 25% ( ) 50% ( ) 100%
8. Would you like to speak with a Social Worker regarding this diagnosis? ( ) Y ( ) N
9. Would you like to speak with a Nutritionist regarding this diagnosis? ( ) Y ( )N

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THE UNIVERSITY OF MICHIGAN

DIVISION OF ALLERGY AND CLINICAL IMMUNOLOGY

1. What problems bring you or your child to an allergist? ________________________________

7. Has your child been diagnosed with Eczema?

9. How were you or your child diagnosed with allergies before?

10. Do you or your child have any other medical problems?

11. Have you or your child been hospitalized before?

12. What medications are you or your child taking?

13. Birth History

a. Were there any problems during pregnancy? ( ) N ( ) Y ___________________

14. Birth weight ________

a. How was your child fed? (check all that apply)

15. Were there any problems tolerating formulas? _______________________

1. Do other people in your family have any of the following conditions?

1. Who lives at home? ____________________________________________________________

2. During the day, your child is: ( ) At home ( ) In day care

5. Since the diagnosis has tension increased in the home?

( ) Not at all ( ) Moderately ( ) Significantly

9. Would you like to speak with a Nutritionist regarding this diagnosis? ( ) Y ( )N

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