Pillar 2 — Describe my situation

Food allergies

Describe the foods, timing, symptoms and care received in one report that you can share yourself.

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Step 1

Who are you completing this form for?

Each choice opens a different questionnaire. If you change pathway, answers specific to the previous pathway are cleared; identity and shared medical history are retained.

Step 2

Pathway Adult and older child

Your questionnaire

Step 1 of 7 · 14 %

1Identity and general informationInformation shown at the top of the summary.

Last nameFirst nameDate of birthScheduled appointment datePrimary care physician or paediatricianOccupation or education

2Medical history, treatments and known allergiesMedical conditions, regular treatments and allergic background.

Chronic conditions or significant medical historyCurrent treatmentsOther known allergies, intolerances or adverse reactions

Personal history of allergy

Allergic rhinitis / conjunctivitisAsthmaEczema / atopic dermatitisKnown food allergy

Family history of allergy?

YesNoI don’t know

Do you take a beta blocker or an ACE inhibitor?

YesNoI don’t know

If you have asthma, how well is it controlled?

Known or suspected latex allergy?

YesNoI don’t know

3Suspected food and timelineFood, amount, preparation, recurrence and time to onset.

Which food was present when the reaction occurred?

PeanutTree nutsMilk and dairy productsEggFishCrustaceans or molluscsWheat or cerealsFruit or vegetableRed meat

Other food or essential detail

How many episodes have you observed?

OneTwo to fiveFrequent or consistent

Date of the most recent reaction

Food state or preparation

Raw / freshCooked / processedJuice / smoothieTrace amount or hidden ingredient in a dish

Amount consumed

Trace / contactSmall amountUsual portion

Had this food previously been tolerated?

YesNoI don’t know

Main delay after the mealTimeline details

4Delayed reactions and foods to document in adultsFish, crustaceans and molluscs should be documented precisely.

If you had repeated vomiting, pallor or marked tiredness several hours after the meal

Select the foods actually consumed. This section helps describe a delayed reaction; it does not confirm FPIES or identify the responsible food.

Specific triggers to document in adults

Shrimp / crustaceansCod / white fishMusselsOther molluscs

5Cofactors and cross-reactivity groupsContext around the meal and food groups already identified.

Were any of these factors present around the reaction?

Exercise or sport around the mealNSAIDs or painkillersAlcoholAcute infection or feverMenstrual periodFatigue or lack of sleepSignificant stress

Have you noticed reactions with any of these groups?

Birch / PR-10: apple, pear, stone fruit, hazelnut, celery, carrotLTP: peach, apple, cherry, tree nuts, peanut, maize, beerLatex-fruit: banana, avocado, kiwi, chestnut, buckwheatProfilins: melon, watermelon, orange, tomato, banana

Details about raw or cooked foods and observed associations

6Observed symptomsWhat was observed or felt, with particular attention to timing.

Are the symptoms happening now?

YesNoI don’t know

Mouth, skin and mucous membranes

Tingling or itching of the lips, mouth or throatLocalised swelling of the lips, tongue or uvulaHives or raised red patchesWidespread itchingSwelling of the face, eyelids or neckRougeur diffuse de la peau

Breathing and circulation

Throat tightness or difficulty swallowingVoice change or hoarsenessCough, wheezing or asthma attackDifficulty breathing or shortness of breathDizziness or light-headednessPalpitations or fast heartbeatLow blood pressure, feeling faint or loss of consciousness

Digestion and delayed symptoms

Nausea or vomiting soon after the mealAbdominal cramps or painAcute diarrhoea soon after the mealRepeated, severe vomiting 1 to 4 hours after the mealMarked pallor, severe fatigue, drowsiness or limpnessDelayed diarrhoea, sometimes 5 to 10 hours after the mealNo skin or respiratory symptoms during this delayed episodeIntermittent vomiting with repeated consumptionChronic diarrhoea or mucous stoolsPoor weight gain or weight lossFeeding refusal or persistent irritability

These answers describe an episode. They cannot confirm an allergy, anaphylaxis or FPIES without medical assessment.

7Care, avoidance and testsCare received, current diet, tests and available documents.

Healthcare used

Primary care physician or paediatricianEmergency medical servicesEmergency departmentHospital admission or prolonged observation

Treatments given

No treatmentAntihistamineCorticosteroidBronchodilator / salbutamolAdrenaline auto-injectorOral rehydration solutionIntravenous fluidsAntiemetic

Number or details of emergency department visitsLaboratory tests performed during emergency careFoods currently avoidedSkin tests or specific IgE tests already performedOral food challenge performed or scheduledNotes to share with the healthcare professional

Photos or visual documents — maximum 5 JPG/PNG files of 10 MB

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Your food allergy form

0 food(s), 0 symptom(s), 0 local photo(s)

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SOS Allergo

Food allergies

Who are you completing this form for?

Pathway Adult and older child

Additional resources