International Oral Immunotherapy Inquiry Sheet

Thank you for inquiring about treatment of food allergies with oral immunotherapy. Please fill this sheet out to help us get to know you a little better so we can formulate the best treatment plan for you or your loved ones.

Demographic information

Patient’s Full Name

Date of Birth

Home Address

Phone Number

Parent’s Names

Email Address

Food Allergy History

List of current food allergies for OIT

Describe allergic history (age at diagnosis, reaction severity, hospitalizations, epinephrine use, etc.)

Previous skin prick testing results

Previous blood testing results

Previous food allergies that have been outgrown, if any.

Environmental allergies? If yes, please list treatments used.

Asthma? If yes, please list treatments used.

Eczema? If yes, please list treatments used.

Please list other pertinent medical history.

A member of our staff will reach out to you once the inquiry is submitted to set up a consultation with Dr. Agrawal. If there are any additional records - such as copies of consultation notes, skin tests or blood tests – that you would like to share, you can email them to freedomallergy@outlook.com.

Thank you again for thinking of Freedom Allergy to help with your food allergy needs!

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