Allergy and Immunology History

Patient Name

Date of Birth

Medical Record Number

Chief Complaint

History of Present Illness

Past Medical History

History of Atopy (asthma, eczema, allergic rhinitis)

Medication and Food Allergies

Medication Allergies Food Allergies Environmental Allergies Reactions to Immunizations

Current Medications

Family History

Social History (Tobacco, Pets, Occupation, Environmental Exposures)

Review of Systems

Physical Examination

Immunization Status