Introduction to the Standardized Allergy Skin test and Immunotherapy forms
The following forms have been developed by the American Academy of Allergy, Asthma and Immunology's Immunotherapy Committee and/or the Joint Task Force: Allergn Immuotherapy: A Practice Parameters Second Update. This is a brief introduction to these forms. There are five sets of forms: skin test forms, immunotherapy prescription forms, immunotherapy administration forms, a pre-immunotherapy injection health screen questionnaire, and the anaphylaxis (systemic reaction) treatment record form. The Immunotherapy Worksheet summarizes important information utilized in immunotherapy prescription writing such as effective therapeutic dose and cross-reactivity between allergens. The information on this worksheet is derived from the Joint Task Force on Practice Parameters Allergen Immunotherapy: A Practice Parameter Second Update, published in the Journal of Allergy and Clinical Immunology in 2007. This worksheet can be laminated and used as a reference when writing immunotherapy prescriptions. The allergy skin test form was developed by the AAAAI Immunotherapy Committee and based on the committee's Guidelines for Reporting Immediate Skin Test Results published in the Academy News in 1999. The immunotherapy prescription and administration forms are based on the Joint Task Force on Practice Parameters Allergen Immunotherapy. The packet also includes a pre-immunotherapy injection health screen questionnaire,an anaphylaxis (systemic reaction) treatment record, example of a cluster and conventional build-up schedule and an example of dose adjustments for unschedules gaps in immunotherapy injections.
- Skin test form
- Blank skin test form
- This form can be used for inhalant or food allergens.
- Example of a completed inhalant skin test form utilizing the above allergens.
- Immunotherapy prescription forms
- Blank immunotherapy prescription form for maintenance concentrate. (projected effective concentration)
- Modification of the blank immunotherapy prescription forms that includes an additional box, which can be used to document any subsequent dilutions for the lower concentrations if they expire prior to the patient completing this step of their buildup.
- Blank prescription form to list component of any mixes used in the immunotherapy vaccine.
- Example of a completed immunotherapy prescription form.
- Immunotherapy administration
This is a two-sided form. The purpose is to document abnormal health screens and other staff interventions that may relate to the immunotherapy injections visit. The health screen is a written or verbal evaluation of the patient's health status that takes place prior to the administration of the immunotherapy injection.
- Blank immunotherapy administration form in portrait format for one and two vials.
- Blank immunotherapy administration form in landscape format for three vials.
- Pre-immunotherapy injection health screenquestionnaire
- Health screen: this page two of the administration form and can be used as to document the results of the pre-injection health evaluation and/or immunotherapy adverse reactions
- Allergen Immunotherapy Administration Form Recommended Documentation
Other documents from the Joint Task Force: Allergn Immuotherapy: A Practice Parameters Second Update:
- Build-up schedule: cluster and conventional
- Schedule for dose modifications for unscheduled gaps in immunotherapy treatment
- Anaphylaxis/Systemic reaction treatment record
- Two methods for grading systemic reactions:EAACI and Portnoy method
Allergen Extract Forms
- Guidelines for Labels for Allergen Immunotherapy Extracts
- Dilution Labeling, Color Coding and Vial Nomenclature
- Probably Effective Dose Range for Allergen Extracts
- Patterns of Allergen Cross-Reactivity
Contact
Home
