Past Medical History
We need to know if you have either an allergic or adverse reaction to any drug, food or insect sting. We need to know the name of the drug, food or insect that you had a reaction to. Please list symptoms such as hives/welts, swelling, shortness of breath, wheezing, throat tightness, loss of consciousness, rash, nausea, vomiting, diarrhea. Please include the date the reaction occured. Also include the ammout of time between ingestion of the drug or food, or insect sting and the beginning of the reaction. (For example, aspirin or shrimp was taken and the reaction started 30 minutes later.) Include any treatment that was needed such as emergency room visits, doctor visits, or over the counter medicines.
Drug One
Drug Two
Drug Two
Drug Two
Please answer yes or no to the  following. Please answer yes only if this is a persistent symptom. If you answer yes, please list doctor, if any who is treating this symptoms. Have you had in the LAST YEAR:
Symptoms
Please list all hospitalisations and surgeries.
Please complete if the patient is less than 10 years of age. Please answer Yes or No.
At what age were solid foods introduced?
Medical Illness