Allergy and Sensitivity Questionnaire

Allergy and Sensitivity Questionnaire — Form Fields

This healthcare template includes 7 fields. Capture patient allergy history including medications, foods, environmental triggers, and reaction severity. Essential for safe treatment planning and anesthesia preparation. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Types of Allergies (select all that apply) (checkboxes, optional) — options: Medication allergy, Food allergy, Environmental allergy (pollen, dust, pet dander), Latex allergy, Insect sting allergy
• Medication Allergies — List medications and reactions (long text, optional)
• Food Allergies — List foods and reactions (long text, optional)
• Have you ever experienced anaphylaxis? (multiple choice, required) — options: Yes, No, Unsure
• Do you carry an epinephrine auto-injector (EpiPen)? (multiple choice, optional) — options: Yes, No
• Additional Allergy Notes (long text, optional)