Pediatric Allergy Consultation Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Pediatric Allergist Note

Patient Identification: [Patient name, age, gender, presenting with...]

History of Present Illness:
[Detailed description of allergy symptoms, onset, duration, frequency, triggers, and any associated features]
[Relevant previous episodes, treatments tried, and response]
[Impact on daily activities, school, and quality of life]

Past Medical History:
(hyphenated list)
- [Chronic illnesses]
- [Previous allergic conditions]
- [Hospitalizations or surgeries]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include over-the-counter and supplements]

Allergies:
(hyphenated list)
- [Drug allergies]
- [Food allergies]
- [Environmental allergies]
- [Other relevant allergies]

Family History:
(hyphenated list)
- [Family members with allergic conditions, asthma, eczema, autoimmune diseases]

Social History:
(hyphenated list)
- [Tobacco exposure: type, amount, duration, quit date if applicable]
- [Pets in home]
- [Environmental exposures: mold, dust, pollen]
- [School/daycare attendance]
- [Living situation: who lives with patient, home environment]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Skin: rashes, eczema, urticaria]
- [HEENT: nasal mucosa, conjunctiva, throat]
- [Respiratory: breath sounds, wheezing, stridor]
- [Other relevant systems]

Investigations:
(hyphenated list)
- [Allergy testing results: skin prick, serum IgE, specific allergen panels]
- [Other relevant labs or imaging]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary allergic diagnosis]

#) [Assessment as a numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Further investigations planned or ordered]
- [Allergen avoidance strategies]
- [Pharmacologic management: antihistamines, inhalers, epinephrine, etc.]
- [Immunotherapy discussion]
- [Education and counselling for patient/family]
- [Referrals to other specialists if needed]
- [Follow up plan]
- [Return precautions]