HFH Food Allergy Registry - Pre-Screening Survey

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Required format:

JAGGpjCBYNWnponYwA3Df4iK5kbbKekk

The registry will be used by Henry Ford allergists and scientists to conduct food allergy research and will help further our understanding of food allergy in children.

Please complete the survey below.

How did you learn about the Food Allergy Registry?

Email invitation

HFH Food Allergy website

My Chart

One Henry website

Friend

Clinic

Other

Do you have a child who has been diagnosed with a food allergy by a physician or health care professional?

Yes

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Is your child less than 18 years of age?

Yes

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Is your child currently being seen by a physician at Henry Ford Health?

Yes

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Has your child ever been seen by a Henry Ford Health provider? (Emergency Room (ER) Physicians, Nurse Practitioner, Primary Care Provider, Specialist, Urgent Care Provider)

Yes

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Parent's first name:

* must provide value

Parent's last name:

* must provide value

Relationship to the child:

* must provide value

Please specify other relationship:

Child's Medical Record Number (MRN):

Child's first name:

* must provide value

Child's last name:

* must provide value

Child's date of birth:

* must provide value

M-D-Y

Street address 1

* must provide value

Street address 2

City

* must provide value

State

* must provide value

Zip Code:

* must provide value

Parent's or Guardian's email:

* must provide value

Parent's or Guardian's preferred phone number

* must provide value

Type of phone:

* must provide value

Cell phone

Home phone

Other

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Thank you for your interest in the HFH Food Allergy Registry. At this time your child doesn't qualify.
If you feel that this is an error, please email foodallergyregistry@hfhs.org

Outcome

Added new Record ID to the Food Allergy Registry

Confirmed existing Record ID in the Food Allergy Registry

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Date

M-D-Y

Comments

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