Allergy/Immunology — Immunotherapy Follow-up Template

Visit Information

Date: [Date]
Visit type: Immunotherapy follow-up / Injection visit / Annual review
Last physician visit: [Date]
Last injection: [Date]

Immunotherapy Status

Treatment Details

Type: SCIT (subcutaneous) / SLIT (sublingual)
Extract type: [Single allergen / Multi-allergen mix]
Allergens: [List]
Start date: [Date]
Current phase: Build-up / Maintenance
Duration on maintenance: [X] months (if applicable)

Current Dosing (SCIT)

Vial	Concentration	Dose (mL)	Frequency
[Color/#]	[1:X]	[X]	[Weekly/biweekly/monthly]

Next dose: [Volume, vial]
Time to maintenance: [X] weeks/already maintenance

Current Dosing (SLIT)

Medication: [Grastek/Ragwitek/Odactra/custom]
Dose: [Dosage unit]
Frequency: Daily
Duration on current dose: [X] months

Interval History

Symptom Control

Overall symptoms since last visit: Better / Same / Worse

Allergic Rhinitis:

Nasal symptoms: None / Mild / Moderate / Severe
Ocular symptoms: None / Mild / Moderate / Severe
Control vs. same season last year: Better / Same / Worse

Asthma (if applicable):

ACT Score: [X]/25
Rescue inhaler use: [X] times/week
Exacerbations: None / [X] — [Steroids, ED, hospitalization]

Seasonal Pattern (if applicable):

Current season symptoms: [Improved from baseline]
Peak season tolerance: [Assessment]

Medication Use

Medication	Previous Use	Current Use	Change
[Drug]	[Frequency]	[Frequency]	[Decreased/Same/Increased]

Antihistamine use: Daily / PRN [X] times/week / Rarely / None
Nasal steroid use: Daily / PRN / Discontinued / None
Rescue medications: [Frequency]

Injection Tolerance (SCIT)

Local Reactions:

Frequency: None / Occasional / Most injections
Size: <2 cm / 2-5 cm / >5 cm
Duration: [X] hours
Treatment needed: None / Ice / Antihistamine

Systemic Reactions Since Last Visit:

[ ] None
[ ] Mild (distant urticaria, rhinitis)
[ ] Moderate (asthma symptoms, generalized urticaria)
[ ] Severe (anaphylaxis)
Details of reactions: [Date, symptoms, treatment, dose]

SLIT Tolerance

Local reactions: None / Oral itching / Mild swelling
Systemic reactions: None / [Description]
GI symptoms: None / [Description]
Compliance: Good / Fair / Poor
Days missed: [X] this month

Injection Record (SCIT)

Recent Injections

Date	Vial	Dose	Site	Local Rxn	Systemic Rxn
[X]	[X]	[X] mL	[L/R deltoid]	[Size]	[None/describe]
[X]	[X]	[X] mL	[Site]	[Size]	[None/describe]

Observation Period Compliance

30-minute wait completed: Yes / No — [If no, reason]

Physical Examination

Vital Signs (Pre-injection)

BP: [X/X]
HR: [X]
Peak flow (if asthmatic): [X] L/min — [X]% personal best

Focused Exam

Injection sites: Normal / [Induration, nodules]
Nasal: [Normal / Pale-boggy / Clear — indicating control]
Lungs: Clear / [Wheezes — hold injection if active asthma]

Current Health Status

Active illness: No / Yes — [Type — may need to hold]
Asthma flare: No / Yes — [Hold if uncontrolled]
New medications: No / Yes — [Especially beta-blockers]
Pregnancy: N/A / No / Yes

Assessment

1) Allergic rhinitis/asthma on immunotherapy

• Phase: [Build-up/Maintenance]
• Duration: [X months/years]
• Response: [Excellent/good/partial/minimal/none]

2) Injection tolerance: Good / Fair / Poor

• Local reactions: [Assessment]
• Systemic reactions: [None/rare/frequent]

3) Overall efficacy assessment:

• Symptom reduction: [X]% estimated
• Medication reduction: [Significant/moderate/minimal/none]

Plan

Today's Injection (SCIT)

[ ] Administered as scheduled

• Vial: [X]
• Dose: [X] mL
• Site: [L/R deltoid/thigh]
• Lot: [X]
• Expiration: [X]
• Administered by: [Name]

[ ] Dose held — Reason: [Illness, reaction, asthma, beta-blocker]
[ ] Dose reduced — Reason: [Large local, systemic reaction]

• New dose: [X] mL

[ ] Dose advanced per schedule

Dose Adjustment Decision

[ ] Continue current schedule
[ ] Advance to next dose: [X] mL
[ ] Repeat current dose — Reason: [Large local, missed dose]
[ ] Reduce dose — Reason: [Reaction, seasonal adjustment]
[ ] Switch to maintenance interval
[ ] Seasonal dose reduction protocol
[ ] Hold pending physician evaluation

SLIT Management

[ ] Continue as prescribed
[ ] Dose adjustment: [Details]
[ ] Address compliance: [Issues]
[ ] Refill prescription: [X tablets]

Premedication

[ ] None needed
[ ] Antihistamine pre-treatment: [Drug, timing]
[ ] Dose splitting: [Protocol]

Reaction Management (if reaction today)

Local reaction:

• [ ] Ice applied
• [ ] Antihistamine given: [Drug]
• [ ] Extended observation

Systemic reaction:

• [ ] Epinephrine [Dose, route, time]
• [ ] Antihistamine [Drug, dose]
• [ ] Steroid [Drug, dose]
• [ ] Bronchodilator [Drug]
• [ ] 911/EMS called
• [ ] Extended observation [X] hours
• [ ] Transferred to ED

Efficacy Optimization

[ ] No changes to concurrent medications
[ ] Add/adjust: [Medication]
[ ] Nasal steroid: [Continue/add/stop]
[ ] Antihistamine: [Continue/add/stop]
[ ] Asthma controller: [Continue/add/adjust]

Duration Assessment

Time on maintenance: [X] months/years
Target duration: [3-5 years]
Continue immunotherapy: Yes / Discuss discontinuation

Patient Education

• Reaction recognition and reporting
• Importance of 30-minute observation
• When to reschedule (illness, asthma flare)
• Epinephrine auto-injector use (if has one)
• Efficacy expectations

Follow-up

Next Injection

Date: [X]
Expected dose: [X] mL from [Vial]

Physician Visit

Next scheduled: [Date]
Purpose: [Annual review, efficacy assessment, end of treatment discussion]

Monitoring

[ ] Peak flow before injections (if asthmatic)
[ ] Symptom diary
[ ] Medication use log

When to Contact Office

• Large local reaction (>palm size, >24 hours)
• Systemic symptoms
• Missed doses
• New medications (especially beta-blockers)
• Pregnancy

Injection Administration Documentation

Injection administered: Yes / No
Time: [X:XX]
Observed until: [X:XX] (minimum 30 minutes)
Condition at discharge: [Stable, no reaction / Reaction resolved]
Patient departed: [X:XX]
Administered by: [Name, credentials]
Supervising physician: [Name]