Name *
Name
Birth Date
Birth Date
Gender
Marital Status
Patient's birth date
Patient's birth date
Has the patient been diagnosed with food allergies?
Who diagnosed you [or the patient] with food allergies? Check all that apply and mention name of the person who conducted the diagnosis in the 'Other' field
List food allergies [Check all food allergies that apply]
Has Epi or Auvi-Q been, or any other epinephrine injectors, prescribed?
Is a physician or any other medical personnel treating you personally?
What did you eat and how much? Where were you, and who prepared the food? How long did it take for symptoms to develop? What were the symptoms and how long did they last for? What did you do about it?
From a scale from (1) to (10) - (1) being lowest confidence and (10) being highest confidence
From a scale from (1) to (10) - (1) being lowest confidence and (10) being highest confidence
Do you feel supported by your family, friends, and coworkers as you manage your food allergies and/or limited diet?
Although an AllerCoach is certified in coaching and food allergy management consulting, I am not a registered physician, psychologist or dietitian . I am not to give medical or clinical advice, nor my services are a replacement for medical care and that no diagnosis will be made. I cannot guarantee allergic reactions will not happen, as new allergies can come on at any time. I do my very best to educate on the highest level of safety.