Pediatric Allergy History
Child's Name
Date of Birth
Sex
Female
Male
Other
Parent/Guardian Name
Contact Information
Describe Past Allergic Reactions
Known Allergens (foods, medications, environmental, etc.)
Age of Onset of Allergies
Reaction Details (symptoms, severity, frequency)
Treatment Used (e.g., epinephrine, antihistamines)
History of Hospitalization for Allergic Reactions
Yes
No
Family History of Allergies or Asthma
Other Medical Conditions
Additional Notes