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Allergy/Immunology Questionnaire Mobile App

Please take a moment to complete the Allergy/Immunology Questionnaire mobile app. It will help the practitioner better understand your symptoms and history from your perspective. Complete all that apply to your history. The app covers allergic/immunologic diseases, symptoms, food allergies, medical episodes, medical conditions and conditions in your home. This app is easy to use on a smartphone or table. This app is specific to allergy patients. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Allergy/Immunology Questionnaire Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

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    Please take a moment to complete this form.

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    **PLEASE BEGIN BY WRITING THE PATIENT’S NAME AND DATE ON EVERY PAGE**

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    Date:

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    Patient Name:

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    Sex:

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    Age:

  • Ico date

    Date of Birth:

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    The main reason for your evaluation:

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    Referred by:

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    Primary Care Physician:

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    Other Physicians you see and their specialties:

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    Drug Allergies:

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    Food Allergies:

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    List all of your current medications, including over-the-counter, vitamins and herbs:

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    Allergy/Asthma Medications

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    All other Medications

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    Over the Counter Medications

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    Vitamins/Supplements

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    Select all allergic/immunologic diseases that apply:

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    Comments

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    Select symptoms that apply

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    List foods causing reactions

  • Ico date

    Date

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    Reaction

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    hives

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    eczema

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    throat swelling

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    facial/eye swelling

  • ...and More!

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