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COVID Reaction High Risk Questionnaire
Thank-you for choosing our practice.
In order to serve you properly we will need the following information.
All information will be STRICTLY CONFIDENTIAL.
Click the "Submit" button at the bottom when completed.
* = Required Field.
Today's Date (mm/dd/yyyy):
*
Patient Last Name:
*
Patient First Name:
*
Patient Date of Birth (mm/dd/yyyy):
*
1. Do you have a history of
severe
allergic reaction to an injectable medication (intravenous, intramuscular, or subcutaneous)?
-If
YES
, please list the specific name of medication
-If
NO
, write None
*
2. Do you have a history of
severe
allergic reaction to a prior vaccine?
-If
YES
, which vaccine(s)
-If
NO
, write None
*
3. Do you have a history of
severe
allergic reaction to another allergen (ex. food, venom, latex)?
-If
YES
, please list
-If
NO
, write none
*
4. Do you have a history of severe allergic reaction to polyethylene glycol (PEG), a polysorbate, or polyoxyl 35 castor oil containing injectable or vaccine?
-If YES, please list
-If NO, write none
*
5. Are you currently taking any anti-histamine containing medications or Pepcid?
Please refer to our website for complete list of meds to avoid prior to testing.
-If YES, please list
-If No, write none
*
6. Are you currently taking a beta-blocker medication?
-If YES, please list
-If NO, write none
*
**PLEASE STOP TAKING ALL ANTI-HISTAMINE CONTAINING MEDICATIONS AT LEAST 7 DAYS PRIOR TO IN OFFICE TESTING APPOINTMENT**