Allergy Record Form

This form is used to document a patient's known allergies, including substances, reported symptoms, severity of reactions, and any special remarks. This information is essential for ensuring safe and personalized medical care.

Patient Information

• Full Name: {fullName}
• Date of Birth: {dateOfBirth}
• Gender: {gender}
• Medical Record Number: {medicalRecordNumber}

Emergency Contact

• Name: {emergencyContactName}
• Relationship: {emergencyContactRelationship}
• Phone Number: {emergencyContactPhone}

Allergy Details

Medications to Avoid

{#medicationsToAvoid}

• {medicationName}

{/medicationsToAvoid}

Special Instructions

{#specialInstructions}

• {instructionText}

{/specialInstructions}

Healthcare Provider

• Provider Name: {providerName}
• Facility: {facilityName}
• Contact Number: {providerPhone}

Date of Record: {dateCompleted}