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Patient Name:DOB:Are you allergic to latex? (please circle)Escudo you have any known allergies? (drug or other) YES NO if YES, please list below:Allergies or Drug Allergies Reaction/Symptoms when
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01
Gather information on any known allergies.
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Read the instructions carefully and fill out the form accurately.
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Specify any allergies to medications, foods, insects, or other substances.
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Who needs are you allergic to?

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Individuals who have known allergies to medications, foods, insects, or other substances should fill out the 'Are you allergic to' form.

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I am allergic to peanuts.
Anyone who has allergies should fill out an allergy form.
You can fill out an allergy form by providing details of your allergies and any medications you take for them.
The purpose of an allergy form is to inform others of your allergies, so they can take necessary precautions.
You must report details of your allergies, symptoms, and any medications or treatments you are currently using.
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