Clinical Biochemistry
Allergy Diagnosis
Reference Guide
Document Number:
BIO NO 116
Author:
Dr. J.Sheldon / L.Miller
Approved by :
L.Miller
Page 10 of 10
Date of Issue: October 2014
Revision: 4
WARNING: This is a controlled document
ALLERGEN SPECIFIC IgE REQUEST FORM
Send completed form to the laboratory with blood sample.
If form is to be matched with a stored sample please fax to 01233 616200.
Enquiries: 01233 616716 - Immunology Laboratory, William Harvey Hospital, Ashford
SURNAME
WARD/CLINIC/GP
FORENAME
CONSULTANT
DATE OF BIRTH
M/F HOSPITAL NUMBER/
NHS NUMBER (Mandatory)
SAMPLE DATE
PATIENT ADDRESS
SAMPLE NUMBER
This must be completed by the requesting clinician following a full clinical history. Guidelines may be found in the
laboratory handbook on Trust Net.
Has the patient ever had a severe reaction (e.g. anaphylaxis) to the suggested
allergen/allergens?
YES/NO
Is there a family history of allergy? YES/NO
Is the patient on any treatment? (please give brief details)
YES/NO
Were the symptoms present at the time of blood collection? YES/NO
Symptoms (please tick as appropriate):
Asthma Bronchitis Catarrh Hay fever Nasal polyps
Abdominal pain Diarrhoea Headache Migraine
Angioedema Arthralgia Nettle rash Urticaria
When do the symptoms occur? (please tick as appropriate)
All year round, Jan, Feb, Mar, Apr, May, June, July, Aug, Sept, Oct, Nov, Dec
When are the symptoms most frequent? (please tick as appropriate)
Outdoors Day time At home On waking
Indoors Night time At work/school Other (please specify)
√
√√
√
SYMPTOMS
(For panels please tick
most appropriate
box/boxes)
SUGGESTED SPECIFIC IgE PANEL
(Panels will be done unless individual allergens are requested in the
bottom section)
Asthma, all year round House dust mite, cat, dog, moulds
Asthma, all year round,
worse at night
House dust mite, cat, dog, mixed feathers
Seasonal rhinitis
House dust mite, cat, dog, mixed grass
(mixed trees, mixed weeds)
Eczema House dust mite, milk in babies, mixed foods in children
Insect venom anaphylaxis Bee, wasp
Peanut allergy Peanut
Wheat intolerance Wheat
Food allergy screen Mixed foods (includes egg, milk, cod, wheat, peanut)
Also available individually – please specify below
Contact with animals: (Please specify)
Individual allergens: (Please specify)
MEDICAL OFFICERS NAME: SIGNATURE:
CONTACT NUMBER: