CAUTION

Important Patient Information

Allergies and Adverse Reactions

Patient Information:
Admission Height: _____cm Weight: ______kg
(Weight: Measured Estimated)
Pregnant Lactating Dialysis
X

List known allergies and adverse reactions below.

Update if new allergies and adverse reactions occur.

 No known allergy / adverse reaction. Initial: _____

Unknown (no information available) Initial: ________

Medications: Reaction Initial Data Entry*

______________________ ____________________ ________
______________________ ____________________ ________
______________________ ____________________ ________
______________________ ____________________ ________
______________________ ____________________ ________
_____________________ ____________________ ________

Latex Allergy: Reaction:

Foods: Reaction Initial Data Entry*
_______________________ ____________________ _________
_______________________ ____________________ _________
_______________________ ____________________ _________
_______________________ ____________________ _________
Other Substances: Reaction Initial Data Entry*
________________________ _____________________ _________
________________________ _____________________ _________
Date: _Todays date__ Date of 1st Revision: ___________________
Date of 2nd Revision: _______________ Date of 3rd Revision: ___________________

* Data entered electronically into required database(s).

Completed form to be forwarded electronically to Pharmacy and to Food Services immediately upon admission, and
upon each revision.
Form to be placed inside front cover of patient’s chart.

Jan 2017