Pre-Surgical Allergy Review Form
Patient Information
Full Name:
Date of Birth:
Medical Record Number:
Surgical Information
Scheduled Procedure:
Surgery Date:
Allergy History
Does the patient have any known allergies?
Yes
No
If yes, list all allergies (medications, foods, latex, etc):
Describe the reaction(s) experienced:
Has the patient had any previous surgical procedures?
Yes
No
If yes, specify procedure(s) and date(s):
Review & Additional Notes
Reviewed By (Clinician):
Review Date:
Additional Notes / Precautions: