Do you consent?
* must provide value
No, I do NOT consent
Yes, I consent
Today M-D-Y mm/dd/yyyy
Are you filling this out for yourself or your child?
* must provide value
Self
My child
Participant's middle initial
First name of the adult filling out this survey
1st Adult's (______ ) email address
What is your relationship to the child?
Is there another adult that should be included?
No
Yes
2nd Adult's (______ ) email address
What is their relationship to the child?
Today M-D-Y
Allergic Individual's Date of Birth
Today M-D-Y
Calculated age at enrollment (years)
View equation Female
Male
Hispanic or Latino
Non Hispanic or Latino
Unknown
select all that apply
Children's Health Medical Record Number (if applicable)
include area code
Is this a home, cell, or work number?
Home
Work
Cell
Secondary contact number?
Is this second number a home, cell, or work number?
Home
Work
Cell
What is your email address?
Are you/your child followed by, or have you/your child seen, an allergy specialist?
No
Yes
Please tell us the name of the specialist
Select 1st food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
To what food are you/your child allergic?
Please only enter 1 single food per line item.
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (1)
Original data for food (1)
Please tell us more about the allergy to ______ .
No
Yes
Reaction after ingestion (1)
Approximate date of first reaction (1)
Approximate date of last reaction (1)
Treatment(s) required (1)
Most recent IgE level in kU/L, if known (1)
leave blank if unknown
Most recent skin test size if known (1)
leave blank if unknown
Are you/your child allergic to another food?
No
Yes
Select 2nd food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (2)
Please only enter 1 single food per line item.
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (2)
Original data for food (2)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (2)
Approximate date of first reaction (2)
Approximate date of last reaction (2)
Treatment(s) required (2)
Most recent IgE level in kU/L, if known (2)
leave blank if unknown
Most recent skin test size if known (2)
leave blank if unknown
Are you/your child allergic to another food? (2)
No
Yes
Select 3rd food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (3)
Please only enter 1 single food per line item.
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (3)
Original data for food (3)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (3)
Approximate date of first reaction (3)
Approximate date of last reaction (3)
Treatment(s) required (3)
Most recent IgE level in kU/L, if known (3)
leave blank if unknown
Most recent skin test size if known (3)
leave blank if unknown
Are you/your child allergic to another food? (3)
No
Yes
Select 4th food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (4)
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (4)
Original data for food (4)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (4)
Approximate date of first reaction (4)
Approximate date of last reaction (4)
Treatment(s) required (4)
Most recent IgE level in kU/L, if known (4)
leave blank if unknown
Most recent skin test size if known (4)
leave blank if unknown
Are you/your child allergic to another food? (4)
No
Yes
Select 5th food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (5)
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (5)
Original data for food (5)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (5)
Approximate date of first reaction (5)
Approximate date of last reaction (5)
Treatment(s) required (5)
Most recent IgE level in kU/L, if known (5)
leave blank if unknown
Most recent skin test size if known (5)
leave blank if unknown
Are you/your child allergic to another food? (5)
No
Yes
Select 6th food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (6)
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (6)
Original data for food (6)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (6)
Approximate date of first reaction (6)
Approximate date of last reaction (6)
Treatment(s) required (6)
Most recent IgE level in kU/L, if known (6)
leave blank if unknown
Most recent skin test size if known (6)
leave blank if unknown
Are you/your child allergic to another food? (6)
No
Yes
Select 7th food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (7)
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (7)
Original data for food (7)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (7)
Approximate date of first reaction (7)
Approximate date of last reaction (7)
Treatment(s) required (7)
Most recent IgE level in kU/L, if known (7)
leave blank if unknown
Most recent skin test size if known (7)
leave blank if unknown
Are you/your child allergic to another food? (7)
No
Yes
Select 8th food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (8)
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (8)
Original data for food (8)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (8)
Approximate date of first reaction (8)
Approximate date of last reaction (8)
Treatment(s) required (8)
Most recent IgE level in kU/L, if known (8)
leave blank if unknown
Most recent skin test size if known (8)
leave blank if unknown
Are you/your child allergic to another food? (8)
No
Yes
Select 9th food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (9)
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (9)
Original data for food (9)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (9)
Approximate date of first reaction (9)
Approximate date of last reaction (9)
Treatment(s) required (9)
Most recent IgE level in kU/L, if known (9)
leave blank if unknown
Most recent skin test size if known (9)
leave blank if unknown
Are you/your child allergic to another food? (9)
No
Yes
Select 10th food that you/your child are allergic.
Peanut
Tree nut
Egg
Milk/Dairy
Fish
Shellfish
Soy
Wheat
Other
What other food are you/your child allergic? (10)
List a tree nut allergy. If you are allergic to more than 1 tree nut, then select "tree nut" again with the next "food" and list another tree nut. (10)
Original data for food (10)
Please tell us more about your allergy to ______ .
No
Yes
Reaction after ingestion (10)
Approximate date of first reaction (10)
Approximate date of last reaction (10)
Treatment(s) required (10)
Most recent IgE level in kU/L, if known (10)
leave blank if unknown
Most recent skin test size if known (food_10)
leave blank if unknown
Do you/your child use albuterol or any other breathing treatments for treating asthma, reactive airway disease, wheezy bronchitis, or a related condition?
No
Yes
Do you/your child have eczema requiring medical treatment (such as steroid creams)?
No
Yes
Do you/your child have allergic rhinitis (e.g. "hay fever" or environmental allergies)?
No
Yes
Have you/your child or anyone in your/your child's immediate or extended family been diagnosed with an allergic condition of the gastrointestinal system (sometimes called "eosinophilic esophagitis," "EE," or "EoE")?
No
Yes
Who in your/your child's family had an allergic GI condition?
Do you/your child have a history of GI upset, "colic," "reflux," persistent difficulty swallowing, or related conditions?
No
Yes
Name of 1st GI upset condition
No
Yes
Is there another GI condition to enter? (1)
No
Yes
Name of 2nd GI upset condition
No
Yes
Is there another GI condition to enter? (2)
No
Yes
Name of 3rd GI upset condition
No
Yes
Do you/your child have any other medical conditions of which we should be aware?
No
Yes
Name of medical condition
Do you/your child have another medical condition? (2)
No
Yes
Name of medical condition (2)
Do you/your child have another medical condition? (3)
No
Yes
Name of medical condition (3)
Do you/your child have another medical condition? (4)
No
Yes
Name of medical condition (4)
Do you/your child have another medical condition? (5)
No
Yes
Name of medical condition (5)
Do you/your child have any other medications of which we should be aware?
No
Yes
Is there another medication?
No
Yes
Is there another medication? (2)
No
Yes
Is there another medication? (3)
No
Yes
Is there another medication? (4)
No
Yes
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