Latex Allergy Screening Questionnaire printable pdf download

Latex Allergy Screening Questionnaire

LATEX ALLERGY SCREENING QUESTIONNAIRE

Name:________________________ Job title:__________________ Work location:__________________

Are you aware of having an allergy to latex? YES NO

If yes, please identify your reaction:

Local rash within minutes of latex exposure / Local rash hours to days after exposure / Worsening Asthma /

Nasal congestion / Itching eyes / Diffuse rash / Urticaria / Facial swelling / SOB / Chest tightness /

Hypotension / Fainting

Do any of the following cause you rashes, irritation or any of the above symptoms (even if mild)?

Balloons / Rubber gloves / Hot water bottles / Rubber bands, balls, grips / Foam pillows / Diaphrams /

Condoms / Latex sexual aids / GYN exams / Digital rectal exams / Dental exams / Enemas / Erasers / Face

masks / Clothing elastic / any other rubber items:___________________________________________

Circle any food items that have ever caused rashes, hives, itching, lip swelling, throat tightness, SOB,

Wheezing or Allergy like symptoms:

Apples / Apricot / Avacado / Bananas / Carrots / Celery / Cherries / Chestnuts / Dates / Figs / Grapes /

Hazelnuts / Kiwi / Mango / Melon / Nectarine / Papaya / Passion fruit / Peaches / Pears / Pineapple / Plums

/ Potatoes / Tomatoes / Wheat

Do you have a history of : Eczema / Asthma / Atopy / Seasonal allergies / Latex sensitivity / Autoimmune

disorders ? YES (circle) NO

Do you ever use latex gloves? YES NO UNSURE

Do your co-workers ever use latex gloves? YES NO UNSURE

Do you have any congenital abnormalities such as Spina Bifida? YES NO

Have you had many childhood surgeries or invasive procedures? YES NO

Have you ever had unexplained intraoperative, hypotension, shock or anaphylaxis? YES NO

Does frequent handwashing cause your hands to break out in a rash? YES NO

Do you use DermaPlus? YES NO Does it help? YES NO

No allergy

Irritant Derm

Type IV latex allergy

Type I latex allergy

NON latex, powdered gloves / DermaPlus / AprilFresh

Work restrictions:

Latex surveillance appointment needed? Yes

Follow-up:

ANUALLY

SEMIANUALLY

NONE NEEDED

Latex Allergy Screening Questionnaire