Allergy Assessment Form

Allergy Assessment Form — Form Fields

This healthcare template includes 8 fields. Documents a patient's known allergies, symptoms, and triggers for clinical evaluation. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Known allergies (select all that apply) (checkboxes, optional) — options: Pollen / Seasonal, Dust mites, Pet dander, Food allergies, Mold, Insect stings, Latex, Medications
• Describe specific allergens (e.g., peanuts, penicillin) (long text, optional)
• Allergy symptoms experienced (checkboxes, optional) — options: Sneezing / runny nose, Hives / skin rash, Difficulty breathing, Anaphylaxis, Itchy / watery eyes
• Have you ever been prescribed an epinephrine auto-injector (EpiPen)? (multiple choice, required) — options: Yes, No
• How would you rate the severity of your allergy symptoms? (dropdown selection, required) — options: Mild, Moderate, Severe
• Additional notes or concerns (long text, optional)