Allergy and Emergency Contact Form

Allergy and Emergency Contact Form

Name of Student*

Discipline*

SLP

Date*

Have you ever had a reaction (redness, swelling, swollen lips, itching skin, eruptions, excessive wheezing or nasal discharge, difficulty breathing) to latex products (balloons, dental dams, condoms, rubber gloves or rubber products)?*

Select

If yes, type your reaction in the box below

Have you ever had a reaction (swelling, swollen lips, itching, excessive wheezing or nasal discharge, difficulty breathing, etc.) to the following fruits: banana, avocado, kiwi, chestnuts, papaya, figs, peach, potato, apple, pineapple, passion fruit, nectarines, plums, cherries, melons, tomato, celery, grapes, apricot?*

Select

If yes, type the fruit and your reaction in the box below

If you answered yes to both of the questions above, please follow up with your primary care doctor (or other duly qualified physician) for testing. If you did not answer yes to both questions, but come into contact with latex while at the hospital and have a reaction, you need to see physician.

Do you have a known latex allergy?*

Select

Do you have any other known allergies, including any life threatening allergies?*

Select

If you answered yes to the previous question, please list your other known allergies below.

To the best of my knowledge, the information provided in this form is true and accurate.

Signature*

Emergency Contact Name*

Emergency Contact Relationship*

Emergency Contact Number*

DISCLAMIER

The questions contained in the document are not intended to diagnose health problems or to take the place of professional medical care. If you need medical advice or answers to personal health questions, you should consult a qualified health care provider. Hospital does not provide testing and assumes no responsibility or liability for your failure to get testing.

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