Immunotherapy Pre-Injection Questionnaire

This questionnaire is designed to optimize safety precautions already in place for your allergen immunotherapy injection (s) (allergy shot).

Please review and answer the following questions. The nursing staff will review your responses and notify your physician if they have any questions or concerns about whether you should receive your injection(s) today. If you are pregnant or have been diagnosed with a new medical condition, please notify the staff.

1. Have you had increased asthma symptoms (chest tightness, increased cough, wheezing, or shortness of breath) in the past week?

Yes No

2. Have you had increased allergy symptoms (itching eyes or nose, sneezing, runny nose, post-nasal drip, or throat-clearing) in the past week?

Yes No

3. Have you had a cold, respiratory tract infection, or flu-like symptoms in the past two weeks?

Yes No

4. Did you have any problems such as increased allergy or asthma symptoms, hives, or generalized itching within 12 hours of receiving your last injection or swelling that persisted into the next day?

Yes No

5. Have you taken an antihistamine in the past 12 hours?

Yes No

6. Have you exercised in the past hour or plan to exercise in the next two hours?

Yes No

7. Are you on any new medications? Any new eye drops? Beta-blockers?

Yes No

8. Are you pregnant?

Yes No

9. Have you been diagnosed with a new medical condition?

Yes No

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Name / Signature

Witness Name / Signature

Date

Your information will be encrypted.

Immunotherapy Pre-Injection Questionnaire

SouthDenver ENT & Allergy