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| Name: ______________________________________ | |||||
| Relationship
(spouse/child etc.): ____________________ |
|||||
| Allergy | Yes/No | Allergy | Yes/No | Allergy | Yes/No |
| Pollens | _______ | Milk | _______ | Penicillin | _______ |
| Molds | _______ | Eggs | _______ | Antibiotics | _______ |
| Dust mites | _______ | Fish | _______ | Sulfa drugs | _______ |
| Animals | _______ | Crustaceans | _______ | Barbiturates | _______ |
| Feathers | _______ | Mollusks | _______ | Anticonvulsants | _______ |
| Insect venom | _______ | Wheat | _______ | Insulin | _______ |
| Kapok | _______ | Nuts | _______ | Novocain | _______ |
| Wool | _______ | Fruits | _______ | Iodine | _______ |
| Smoke | _______ | Chocolate | _______ | Caine anesthetics | _______ |
| Perfume | _______ | Sugar | _______ | Physical agents | _______ |
| Nitrate | _______ | Other: | _______ | ||
| Sulfates | _______ | Other: | _______ | ||