Health Information Template

Monday, 26 October 2009 02:02 |

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

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

*Food*	*Reaction*
Dairy food	Allergic rhinitis, asthma, eczema
Wheat	Severe allergic rhinitis,
Egg	Anaphylaxis, eczema
Shellfish	Anaphylaxis,
Pineapple	Eczema, asthma,

Specific Food sensitivities/reactions

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

*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

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

ASEHA Qld

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