Allergy/Immunology — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary allergic/immunologic concern]
Duration: [X] days/weeks/months/years
Current status: Improving / Stable / Worsening / Seasonal

History of Present Illness

For Allergic Rhinitis

Nasal Symptoms:

Rhinorrhea: None / Mild / Moderate / Severe

• Character: Clear / Colored

Nasal congestion: None / Mild / Moderate / Severe

• Unilateral / Bilateral / Alternating

Sneezing: None / Occasional / Frequent paroxysms
Nasal itching: None / Mild / Moderate / Severe
Post-nasal drip: None / Present

Ocular Symptoms:

Itching: None / Mild / Moderate / Severe
Watering: None / Mild / Moderate / Severe
Redness: None / Present
Swelling: None / Present

Pattern:

Seasonal: Yes / No — Seasons: [Spring, summer, fall, winter]
Perennial: Yes / No — Worse certain times: [X]
Intermittent (<4 days/week or <4 weeks) / Persistent (≥4 days/week and ≥4 weeks)
Severity: Mild / Moderate-severe

ARIA Classification:

[ ] Intermittent mild
[ ] Intermittent moderate-severe
[ ] Persistent mild
[ ] Persistent moderate-severe

Impact:

Sleep disturbance: None / Mild / Moderate / Severe
Work/school impairment: None / Mild / Moderate / Severe
Daily activities: Normal / Impaired
Quality of life: Normal / Reduced

Triggers Identified:

[ ] Pollens — [Tree, grass, weed]
[ ] Dust mites
[ ] Mold
[ ] Animal dander — [Cat, dog, other]
[ ] Cockroach
[ ] Occupational: [Exposure]
[ ] Irritants — [Smoke, perfume, cleaning products]
[ ] Unknown

For Asthma/Reactive Airways

Current Symptoms:

Wheezing: None / Present — [Frequency]
Cough: None / Present — [Dry, productive, nocturnal]
Shortness of breath: None / Present — [Triggers]
Chest tightness: None / Present

Symptom Pattern:

Daytime symptoms: [X] times per week
Nighttime awakening: [X] times per month
Rescue inhaler use: [X] times per week
Activity limitation: None / Present

Asthma Control Assessment:

ACT Score: [X]/25 — [Well controlled ≥20, not well controlled 16-19, very poorly controlled ≤15]
ACQ Score: [X]

Triggers:

[ ] Allergens — [Specific]
[ ] Exercise
[ ] Cold air
[ ] Respiratory infections
[ ] Irritants/smoke
[ ] Emotions/stress
[ ] GERD
[ ] Menstrual (if female)
[ ] Occupational: [Exposure]
[ ] Aspirin/NSAIDs
[ ] Beta-blockers

Exacerbations:

Exacerbations past year: [X]
ED visits past year: [X]
Hospitalizations past year: [X]
ICU admissions ever: No / Yes — [Intubation]
Oral steroids past year: [X] courses

Severity Classification:

[ ] Intermittent
[ ] Mild persistent
[ ] Moderate persistent
[ ] Severe persistent

For Food Allergy

Suspected Foods:

Food	Reaction	Timing	Severity
[Food]	[Symptoms]	[Minutes/hours]	[Mild/moderate/severe]

Reaction Details:

Most recent reaction: [Date, food, symptoms]
Typical symptoms:

• [ ] Oral itching/tingling
• [ ] Hives
• [ ] Angioedema
• [ ] Vomiting/abdominal pain
• [ ] Respiratory symptoms
• [ ] Anaphylaxis

Risk Factors:

Asthma: No / Yes — [Control]
History of anaphylaxis: No / Yes
Epinephrine auto-injector: Have / Don't have / Expired

Diet:

Current avoidance: [Foods avoided]
Accidental exposures: [Frequency, outcomes]
Label reading: Yes / No
Dining out comfort: Comfortable / Avoid / With precautions

For Drug Allergy

Reported Reaction:

Drug: [Name, class]
Reaction: [Description]
Timing: [Immediate/delayed]
Severity: [Mild/moderate/severe/anaphylaxis]
When: [Date/years ago]
Treatment required: [None/antihistamine/steroids/epinephrine/hospitalization]

Current Need:

Need for drug/class: No / Yes — [Indication]
Alternatives available: Yes / No
Desensitization considered: Yes / No

For Urticaria/Angioedema

Pattern:

Acute (<6 weeks) / Chronic (≥6 weeks)
Duration of current episode: [X]
Frequency: [Daily, several times/week, etc.]
Duration of individual hives: [Hours]

Characteristics:

Location: [Generalized, localized]
Size: [Small, large, confluent]
Pruritus: Mild / Moderate / Severe
Angioedema: No / Yes — [Location]

Triggers Identified:

[ ] None identified (spontaneous)
[ ] Foods: [X]
[ ] Medications: [X]
[ ] Physical: [Pressure, cold, heat, exercise, sun]
[ ] Infections
[ ] Stress

Associated Symptoms:

Respiratory: None / [Symptoms]
GI: None / [Symptoms]
Hypotension: None / Present

Impact:

Sleep: Normal / Disturbed
QoL: Normal / Impaired
Work/school: Normal / Missed [X] days

For Anaphylaxis History

Episode(s):

Number of lifetime episodes: [X]
Most recent: [Date]
Severity: [Mild/moderate/severe/cardiac arrest]

Identified Trigger:

[ ] Food: [Specific]
[ ] Medication: [Specific]
[ ] Insect sting: [Type]
[ ] Exercise
[ ] Idiopathic
[ ] Other: [X]

Symptoms During Episodes:

[ ] Skin (hives, flushing, itching): [X]%
[ ] Respiratory (dyspnea, wheeze, throat): [X]%
[ ] GI (nausea, vomiting, pain): [X]%
[ ] Cardiovascular (hypotension, syncope): [X]%

Treatment Required:

Epinephrine: [Self-administered, EMS, ED]
ED visits: [Number]
Hospitalizations: [Number]

Current Preparedness:

Epinephrine auto-injector: Have current / Expired / Don't have
Trained in use: Yes / No
Action plan: Have / Don't have
Medical alert: Wears / Doesn't wear

For Immunodeficiency Evaluation

Infection History:

Sinusitis: [X] per year — [Requiring antibiotics]
Pneumonia: [X] lifetime — [Hospitalized]
Bronchitis: [X] per year
Otitis media: [X] per year
Skin infections: [Frequency]
Other serious infections: [List]

Red Flags for Immunodeficiency:

[ ] ≥4 ear infections in one year
[ ] ≥2 serious sinus infections in one year
[ ] ≥2 months on antibiotics with little effect
[ ] ≥2 pneumonias in one year
[ ] Failure to thrive (if child)
[ ] Recurrent deep skin or organ abscesses
[ ] Persistent thrush or skin fungal infections
[ ] Need for IV antibiotics
[ ] ≥2 deep-seated infections
[ ] Family history of immunodeficiency

Allergy Testing History

Previous Testing

Skin prick testing: Not done / Done [Date]

• Positives: [List]
• Negatives: [List]

Specific IgE (blood): Not done / Done [Date]

• Results: [List]

Food challenges: Not done / Done

• Results: [Food, outcome]

Drug challenge/testing: Not done / Done

• Results: [Drug, outcome]

Pulmonary function: Not done / Done [Date]

• FEV1: [X]% predicted
• FEV1/FVC: [X]%
• Bronchodilator response: [X]% improvement

Treatment History

Current Medications

Medication	Dose	Frequency	Duration	Efficacy
[Drug]	[Dose]	[X times/day]	[X months]	[Good/partial/poor]

Allergy medications:

• Oral antihistamines: [Drug, response]
• Nasal steroids: [Drug, response]
• Nasal antihistamines: [Drug, response]
• Eye drops: [Drug, response]
• Decongestants: [Drug, response]

Asthma medications (if applicable):

• Controller: [Drug, dose]
• Rescue: [Drug, frequency]
• Add-on: [Drug]

Immunotherapy:

• Prior SCIT: No / Yes — [Duration, response]
• Prior SLIT: No / Yes — [Drug, response]

Environmental Controls

Dust mite measures: None / [Encasements, etc.]
HEPA filters: No / Yes
Pet avoidance: N/A / Removed / Can't remove
Other: [Measures tried]

Past Medical History

Atopic dermatitis/eczema: No / Yes — [Severity, treatment]
Asthma: No / Yes — [As above]
Nasal polyps: No / Yes
GERD: No / Yes — [Treatment]
Sleep apnea: No / Yes
Sinus surgery: No / Yes — [Date]
Autoimmune disease: No / Yes — [Type]
Malignancy: No / Yes — [Type]
HIV/immunosuppression: No / Yes

Family History

Allergic rhinitis: No / Yes — [Relationship]
Asthma: No / Yes — [Relationship]
Eczema: No / Yes — [Relationship]
Food allergy: No / Yes — [Relationship]
Drug allergy: No / Yes — [Relationship]
Anaphylaxis: No / Yes — [Relationship]
Immunodeficiency: No / Yes — [Relationship]

Social/Environmental History

Home type: House / Apartment / [Other]
Age of home: [X] years
Carpet: Yes / No — [Extent]
Pets: None / [Type, indoor/outdoor]
Smoking: Current / Former / Never — Secondhand: [Exposure]
Occupation: [Type, exposures]
Hobbies: [Relevant exposures]
Geographic: [Region, relevant allergens]

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
RR: [X]
Temp: [X]°F
SpO2: [X]%
Weight: [X] — BMI: [X]

General

Appearance: Well / [In distress, allergic facies]
Allergic shiners: Absent / Present
Dennie-Morgan lines: Absent / Present

HEENT

Eyes:

Conjunctival injection: None / [Bilateral]
Chemosis: None / Present
Tearing: None / Present
Allergic shiners: Absent / Present

Nose:

External: Normal / [Transverse crease]
Turbinates: Normal / Pale-boggy / Erythematous / Enlarged
Mucosa: Pink-moist / [Pale, edematous]
Discharge: None / [Clear, purulent]
Polyps: None / Present
Septum: Midline / Deviated

Throat:

Tonsils: Normal / [Enlarged, cobblestoning]
Posterior pharynx: Normal / [Cobblestoning, drainage]

Ears:

TMs: Normal / [Effusion, retraction]

Pulmonary

Respiratory distress: None / [Present]
Breath sounds: Clear / [Wheezes, decreased]
Forced expiratory time: [X] seconds
Peak flow (if done): [X] L/min — [X]% predicted

Skin

Urticaria: None / Present — [Distribution, size]
Angioedema: None / Present — [Location]
Eczema: None / Present — [Distribution, severity]
Dermographism: Negative / Positive

Other

Lymphadenopathy: None / [Location]
Hepatosplenomegaly: None / Present

Allergy Testing Today

Skin Prick Testing

Performed: Yes / No / Deferred

Aeroallergens:

Allergen	Wheal (mm)	Flare (mm)	Result
Histamine (positive)	[X]	[X]	Control
Saline (negative)	[X]	[X]	Control
Dust mite (D. farinae)	[X]	[X]	+/-
Dust mite (D. pteronyssinus)	[X]	[X]	+/-
Cat	[X]	[X]	+/-
Dog	[X]	[X]	+/-
[Tree pollens]	[X]	[X]	+/-
[Grass pollens]	[X]	[X]	+/-
[Weed pollens]	[X]	[X]	+/-
Mold (Alternaria)	[X]	[X]	+/-
Mold (Aspergillus)	[X]	[X]	+/-
Cockroach	[X]	[X]	+/-

Food Allergens (if indicated):

Allergen	Wheal (mm)	Flare (mm)	Result
[Food]	[X]	[X]	+/-

Spirometry (if performed)

Pre-bronchodilator:

• FVC: [X] L ([X]% predicted)
• FEV1: [X] L ([X]% predicted)
• FEV1/FVC: [X]%
• FEF 25-75: [X] L/s ([X]% predicted)

Post-bronchodilator:

• FEV1: [X] L — Change: [X]% (≥12% and ≥200 mL = positive)

Pattern: Normal / Obstructive / Restrictive
Reversibility: Yes / No

Other Testing

FeNO: [X] ppb — [Normal <25, elevated 25-50, high >50]
Peak flow: [X] L/min — [X]% predicted
Specific IgE ordered: [List]

Assessment

1) [Primary allergic/immunologic diagnosis]
Severity: [Mild/moderate/severe]
Control: [Well-controlled/not well-controlled/poorly controlled]
Pattern: [Intermittent/persistent, seasonal/perennial]
2) [Secondary diagnoses]
3) Sensitizations identified: [List positive allergens]
4) [Contributing factors]

Plan

Allergen Avoidance

Environmental controls recommended:

• [ ] Dust mite: Encasements, humidity control, wash bedding hot
• [ ] Pet dander: [Keep out of bedroom, HEPA, remove if possible]
• [ ] Pollen: Windows closed, shower after outdoor, HEPA
• [ ] Mold: Fix leaks, dehumidifier, HEPA
• [ ] Cockroach: Pest control, seal cracks
• Food avoidance: [Specific foods, label reading education]

Pharmacotherapy

Allergic Rhinitis:

• [ ] Intranasal corticosteroid: [Drug, dose]
• [ ] Oral antihistamine: [Drug, dose]
• [ ] Intranasal antihistamine: [Drug, dose]
• [ ] Combination nasal spray: [Drug]
• [ ] Decongestant (short-term): [Drug]
• [ ] Nasal saline irrigation
• [ ] Leukotriene modifier: [Drug, dose]

Asthma:

• [ ] Controller: [ICS or ICS/LABA, drug, dose]
• [ ] LAMA: [If indicated]
• [ ] Rescue: [SABA]
• [ ] Biologic: [If severe asthma]
• [ ] Asthma action plan provided

Urticaria:

• [ ] H1 antihistamine: [Drug, dose — up to 4x standard]
• [ ] H2 antihistamine: [Drug, dose]
• [ ] Leukotriene modifier: [Drug]
• [ ] Omalizumab: [If chronic refractory]
• [ ] Cyclosporine: [If severe refractory]

Anaphylaxis Preparedness:

• [ ] Epinephrine auto-injector: [Dose, quantity]
• [ ] Anaphylaxis action plan
• [ ] Medical alert recommendation

Immunotherapy

• [ ] Not indicated at this time
• [ ] Discussed — Patient considering
• [ ] Initiate SCIT: [Build-up schedule, maintenance]
• [ ] Initiate SLIT: [Drug — Grastek, Ragwitek, Odactra]

Immunotherapy candidacy:

• Sensitization correlates with symptoms: Yes / No
• Failed/inadequate response to medications: Yes / No
• Able to commit to treatment course: Yes / No

Additional Testing

• [ ] Specific IgE panel: [Allergens]
• [ ] Component testing: [Foods]
• [ ] Tryptase (if mast cell concern)
• [ ] Immunoglobulin levels (if immunodeficiency)
• [ ] Complete PFTs
• [ ] Methacholine challenge
• [ ] Food challenge
• [ ] Drug challenge/testing
• [ ] CT sinus

Referrals

• [ ] ENT (chronic sinusitis, polyps)
• [ ] Pulmonology (severe/complex asthma)
• [ ] Dermatology (complex urticaria, eczema)
• [ ] Gastroenterology (EoE, food allergy)
• [ ] Immunology (immunodeficiency)
• [ ] Dietitian (food allergy)
• [ ] Other: [Specialty]

Patient Education

• Diagnosis and trigger avoidance
• Medication use (nasal spray technique, inhaler technique)
• Epinephrine use (if prescribed)
• Anaphylaxis recognition
• Action plan review
• When to seek emergency care

Follow-up

Return: [X] weeks/months for [Purpose]

• Reassess control
• Review medication efficacy
• Immunotherapy discussion/initiation
• Repeat testing

Sooner if: Worsening symptoms, reaction, medication issues

Communication

Discussed with patient/family: [Topics covered]
Report sent to: [Referring physician, PCP]
Action plan provided: Yes / No
Epinephrine prescription: [If applicable]