Pre-Employment Allergy Screening Form
Personal Information
Full Name
Date of Birth
Email
Phone
Allergy Information
Do you have a history of allergies?
Yes
No
Type(s) of Allergy (check all that apply)
Pollen
Dust
Food
Drug
Insect Stings
Latex
Other
If other, please specify
Describe any reactions experienced
Are you currently taking any allergy medications?
Yes
No
If yes, please specify
Emergency Information
Emergency Contact Name
Emergency Contact Phone
Signature
Date