Pediatric Allergy Assessment Form
Patient Information
Child's Name
Date of Birth
Gender
Male
Female
Other
Parent/Guardian Name
Contact Number
Allergy History
Known Allergies (list)
Describe Reaction(s)
Age at Onset
Treatment Given
Medical History
History of Asthma?
Yes
No
History of Eczema?
Yes
No
Family History of Allergy?
Yes
No
Other Medical Conditions
Environmental/Exposure History
Pets at Home?
Yes
No
Exposure to Tobacco Smoke?
Yes
No
Other Notable Exposures
Current Medications
List Current Medications
Additional Notes
Notes