New Patient Allergy History Intake
Full Name
Date of Birth
Phone Number
Allergy History
Do you have any allergies?
Yes
No
Please list all known allergies (e.g. medications, foods, environmental):
Description of reaction(s) (if any):
When did you first notice these allergy/allergies?
Have you ever required emergency treatment (such as EpiPen, hospital, etc.) for an allergic reaction?
Yes
No
Additional Comments / Notes