Eosinophilic Esophagitis (EoE) Screening & Assessment Form

Streamline Eosinophilic Esophagitis Screening with Paperform

Eosinophilic esophagitis (EoE) is a chronic immune-mediated condition that requires thorough patient assessment and careful symptom tracking. Our Eosinophilic Esophagitis Screening & Assessment Form template helps gastroenterology practices, allergy clinics, and healthcare providers efficiently collect critical patient information, assess symptom severity, and coordinate diagnostic procedures—all in one streamlined workflow.

Why Healthcare Providers Choose This Template

This template is specifically designed for gastroenterologists, allergists, and GI nursing staff who need to gather comprehensive EoE-related information before consultations or endoscopic procedures. Rather than juggling paper forms, phone calls, and scattered patient histories, this digital form captures everything from dysphagia frequency and food impaction episodes to detailed allergy histories and medication usage.

Key benefits for your practice:

• Comprehensive symptom assessment that captures dysphagia severity, food impaction history, and trigger foods
• Allergy and medical history integration to identify potential EoE triggers and comorbidities
• Appointment scheduling for endoscopy procedures and gastroenterology consultations
• Conditional logic that adapts questions based on symptom severity and patient responses
• HIPAA-friendly data collection with SOC 2 Type II compliance and secure data handling

Perfect for Multiple Healthcare Settings

This form template serves various healthcare professionals managing EoE patients:

Gastroenterology Practices: Collect pre-visit assessments, track treatment response, and schedule endoscopy procedures with built-in calendar integration.

Allergy & Immunology Clinics: Document allergic conditions, previous testing results, and coordinate care with GI specialists when EoE is suspected.

Pediatric GI Specialists: Adapted easily for pediatric populations where EoE commonly presents with feeding difficulties and growth concerns.

Hospital GI Departments: Streamline patient intake for endoscopy scheduling and ensure all necessary pre-procedure information is collected upfront.

From Screening to Consultation in One Form

Traditional patient intake often involves multiple phone calls, incomplete forms, and delayed scheduling. This template transforms that experience into a single, intelligent form that:

1. Assesses current symptoms including dysphagia frequency, food getting stuck, chest pain, and heartburn
2. Documents food impaction episodes with detail on severity, frequency, and emergency department visits
3. Captures comprehensive allergy history including food allergies, environmental allergies, asthma, and eczema
4. Reviews current medications and previous treatments for reflux or allergic conditions
5. Collects dietary information to identify potential trigger foods
6. Schedules appointments for endoscopy procedures or gastroenterology consultations directly within the form

With Paperform's conditional logic, patients only see questions relevant to their specific situation. If a patient reports frequent food impaction, the form automatically expands to gather critical details about those episodes without overwhelming patients with unnecessary questions.

Automate Your Clinical Workflow with Stepper

Once a patient submits their EoE screening form, Stepper can automatically orchestrate your entire clinical workflow. Route urgent cases (like recent food impaction requiring emergency intervention) to immediate physician review, send routine assessments to your scheduling coordinator, and automatically update your EMR system with new patient information.

You can set up workflows that:

• Alert providers when high-risk symptoms are reported
• Automatically schedule endoscopy based on symptom severity
• Send pre-procedure instructions to patients who need upper endoscopy
• Create follow-up tasks for allergy testing coordination
• Update patient records in your practice management system

On-Brand Patient Experience

Healthcare is personal, and your forms should reflect your practice's professionalism. With Paperform's doc-style editor, you can customize this template to match your clinic's branding—add your practice logo, adjust colors to match your website, and include reassuring messaging about the screening process.

The form works beautifully on any device, so patients can complete their assessment from their phone while in your waiting room or from home days before their appointment. You can embed it directly on your practice website or send it as a standalone link via your patient portal or email.

Secure, Compliant, and Trusted

Patient health information requires the highest security standards. Paperform is SOC 2 Type II compliant and provides robust data protection features including SSL encryption, data residency controls, and secure submission storage. While not HIPAA-compliant, Paperform offers enterprise-grade security suitable for many healthcare administrative and screening workflows.

Designed for Healthcare Professionals

Whether you're a gastroenterologist managing a busy EoE clinic, an allergist screening patients for esophageal involvement, a GI nurse coordinator scheduling endoscopies, or a healthcare administrator streamlining patient intake, this template gives you the structure and flexibility to capture exactly what you need.

Over 500,000 teams worldwide trust Paperform for their critical workflows. Join healthcare practices that have replaced clunky paper forms and fragmented intake processes with intelligent, automated patient screening that improves care coordination and saves valuable clinical time.

Get started with this template today and transform how you assess and manage eosinophilic esophagitis patients in your practice.