PostHeaderIcon Health Information Template

Disability and Medical Issues For MCS and Allergy - Access to Medical Practitioners and Health Service

The following is a template of the health information that needs to be provided to the hospital at the start of consultations with them and prior to hospital admission. This list will need to be refined for each individual.

A single page SUMMARY REACTION TABLE (last page of this document) will provide hospital staff with a quick reference of your particular reactants. The list can flag where additional important information is detailed within this document.

Contact Information

Name:
Address:
Phone:
Family contact:
GP for treating allergy, food and chemical sensitivity:

Disability Requirements

General considerations for disability access: EgAll staff need to be fragrance free, Patient may not be attended by a smoker, Avoid latex gloves
Disability accommodation needs: Eg Non carpeted room, single accommodation, fragrance free, not recently treated with pesticides etc

Hospital Personnel

Personnel for inclusion in team for pre-surgery conference
Contact Name
Senior pharmacist
Physiotherapist
Social worker
Nurse in charge of patient special needs
Dietician

Occupational therapist
Anaesthetist



Allergy, Food and Chemical Sensitivity List:

Allergen/reaction Eg
Allergen Reaction

House dust


Severe hay fever, fatigue, eczema, asthma


Mould


Mild anaphylaxis, migraine, severe fatigue, asthma


Wool


Hay fever, eczema, asthma


Pollen


Severe hay fever, asthma


Fragrances


Anaphylaxis, migraine, peripheral neuropathy, asthma


Smoke


Anaphylaxis, migraine, chemical induced pneumonitis, asthma


Pyrethrums


Anaphylaxis, migraine, asthma


Formaldehyde


Anaphylaxis, asthma

Dietary requirements

General Requirements: Only fresh, organic whole foods are tolerated. No processed, packaged, canned or frozen foods are allowed as they usually contain additives. Chemicals from packaging materials e.g. phthalates from plastics can leach into the food and causes reactions. A low phenolic diet must be observed. Additives in table one are common and are to be avoided at all times.

Table 1.  Food additives that commonly cause reactions in individuals with food and chemical sensitivities



Food additives to avoid in food, medications and supplements


Colorings


102, 107, 110, 122, 123, 124, 127, 160(b)


Preservatives


132, 133, 142, 151, 155


Benzoic acids


210, 211, 212, 213


Propionic acids


281, 282, 283



Sorbic acids


200, 201, 202, 203


Sulphites


220, 221, 222, 223, 224, 225, 226, 227, 228


Nitrates


251, 252


Nitrites


249, 250


Anti-oxidants


310, 311, 312, 320, 321


Glutamates


620, 621, 622, 623


Flavourings


Avoid all


Artificial sweeteners


Avoid all

 

Specific Food allergens/reactions

Eg



Food


Reaction


Dairy food


Allergic rhinitis, asthma, eczema


Wheat


Severe allergic rhinitis,


Egg


Anaphylaxis, eczema


Shellfish


Anaphylaxis,



Pineapple


Eczema, asthma,








 

Specific Food sensitivities/reactions

Eg



Vegetables


Fruits


Herbs/spices


Other


Parsnip


Tomato


Mustard


Gluten


Pepper


Pear


Garlic


Lactose


Celery


Grapes, sultanas


Herbs - many





Broccoli


Citrus Fruits


Bay leaves





Cauliflower


Berries







Turnip


Stone fruits







Leek


Banana







Brussels sprouts


Rockmelon, watermelon






Cabbage


Rhubarb







Cucumber









Capsicum red/green









Carrot














Potato











Specific Chemical sensitivities/reactions

(Tick appropriate boxes and list reactions e.g. respiratory difficulties, rash, headache, gastrointestinal symptoms etc)



Chemical


Reaction


Pesticides

Organochlorines

Organophosphates

Pyrtherum

Carbamates

Other………………..







Paints, stains





Formaldehyde





Solvents

Xylene

Benzene

Toluene

Other…………….








Synthetic fabrics





Fragrances – perfumes, air fresheners, deodorants





Cleaning products

Detergents

Disinfectants







Phenolic compounds





Essential oils





Terpenes





Motor exhaust





Chlorine based products





Fungicides





















 

Medication: Specific requirements

General Considerations: Drug reactions are common due to salicylate/amine sensitivity. Avoid additives such as preservatives, colourings, flavourings, antioxidants, MSG or artificial sweeteners. 
Ensure the following fillers are not used in medications e.g. grains, gluten, lactose, soya, rice.

Specific Requirements Eg



Medication


Reaction


Penicillin


Anaphylaxis, rash


Aspirin and aspirin based drugs/creams (phenolic compounds), Codeine, Panadein, Mersyndol, Oil of wintergreen


Can cause anaphylaxis - exacerbate symptoms e.g. migraine, joint muscle pain, peripheral neuropathy, irritate kidneys, affect gut


Anti inflammatory meds


Contraindicated - Peptic ulcer


Valium


Contraindicated - Chronic irritable bowel disease


Steroids, hormones


Can cause allergic reactions, very severe migraine,


Puffers


Allergy, severe chest pain


Sedatives


These can cause the reverse effect and hyperactivate


Pethidine


Severe migraine


Anaesthetics


Poor recovery


Dextrose drips


Ensure these are not corn based due to corn allergy


Iodine and other dyes


Can cause anaphylaxis

 

Medical equipment: Specific requirements Eg

Equipment


Reaction


Plastic


Plastic tubing, oxygen masks. Glass tubing or ceramic mask is preferred over plastic. Keep plastic to a minimum. Plastic tubing - observe for any reaction.
These may include but are not limited to edema, itching or other irritation at the site where tubing contacts the skin, itchy veins, burning veins, hot flushing, chilling.

For IV fluids use normal saline in glass bottles instead of plastic as much as possible. Soft plastics such as those used for IV drips and blood bags contain phthalates, which are toxic chemicals and can cause reactions in chemically sensitive individuals. If dextrose is required check that it is not corn based.


Adhesive tape


Most adhesive tapes


Latex


Avoid latex gloves


Iodine


Do not use preparations with iodine, dyes other colourings or preservatives


Disinfectants


With care

 

Medical history:


Test Results:

Test results to substantiate your documentation are recommended, or confirmation of these problems provided in writing from your health care practitioner


NAME:

SUMMARY REACTION TABLE
Some examples are provided in the table below


MOST SEVERE
Symptoms may vary depending on the actual substance, type of exposure & amount.


SUBSTANCE


MAIN EFFECT


Aspirin


Anaphylaxis


Formaldehyde


Severe respiratory effects


Peanut


Anaphylaxis


Perfumes


Severe migraine, severe respiratory effects, asthma


Pesticides


Asthma, severe migraine, debilitating pain. *See Health Information form for more detail on pesticide types












































MUST AVOID Symptoms may vary depending on the actual substance, type of exposure & amount.


SUBSTANCE


MAIN EFFECT


Essential oils


Headache


Non organic, processed foods


PROVIDING OWN FOOD


Wool


Hay fever, eczema




















DISCOMFORT Symptoms may vary depending on the actual substance, type of exposure & amount.


SUBSTANCE


MAIN EFFECT


Yeast


Bloating































Examples of MOST SEVERE effects: Anaphylaxis, Severe respiratory symptoms, Debilitating pain, Severe migraine/headache, Cardiac symptoms

Examples of MUST AVOID effects: Headache, Bleeding, Pain, Palpitations, Laryngitis, Skin rash, Rhinitis, Sinusitis

Examples of DISCOMFORT effects: Disorientation, Brain fog, Bloating, Dyspepsia

The information in this table will be very individual, and what is Discomfort for one person can be a MUST AVOID for another. For most MCS people the Most Severe category will be the largest.

When it comes to foods, if you can only eat organic, unprocessed food it will be better to arrange for your meals to be brought in. If you can eat hospital meals but react to yeast - this should be included in your table.

It is in your best interests that this list as clear and concise as possible so that hospital staff can easily and quickly access this information. List the substances in each category alphabetically

Last Updated (Tuesday, 17 November 2009 01:28)