Idiopathic Anaphylaxis Questionnaire and Reporting Form

Idiopathic anaphylaxis appears to be increasing in prevalence, is frequently associated with fatality, and is a disease diagnosed and treated almost exclusively by the allergy specialist. The ACCAI Drug Allergy and Anaphylaxis Committee is collecting data on idiopathic anaphylaxis for tabulation and dissemination to allergy specialists.

The Idiopathic Anaphylaxis Questionnaire can be used for reporting cases to the College. You may download the form and make duplicate copies for each patient of record and for any new patients that you diagnose with idiopathic anaphylaxis.

Because of the format of the form, we have chosen to provide it in Adobe's Portable Document Format (PDF).

The form should be mailed of faxed to the ACCAI Executive Office, 85 W. Algonquin Road, Suite 550, Arlington Heights, IL 60005 - Fax (847) 427 - 1294.