Drug Reaction Chart - Allergy Associates And Asthma
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1
2ALLERGY ASSOCIATES & ASTHMA, LTD.
1006 E. Guadalupe Rd., Tempe, AZ 85283
6553 E. Baywood Ave, Ste. 103, Mesa AZ 85206
2248 N. Alma School Rd., Chandler, AZ 85224
Phone: (480) 838-4296
Fax: (480) 820-1275
Dr. Suresh Anand
Dr. Miriam Anand
Veena Krause, F.N.P.
Tera Crisalida, P.A.-C.
Tempe
Mesa
Chandler
PLEASE USE A SEPARATE FORM FOR EACH MEDICATION
Patient Name: _____________________________ Acct #:_____________ Date:__________________
Name of the medication to which you reacted:____________________________________________
How was the medication given? (Please check)
□ Orally (pill, syrup, etc.)
□ IV (intravenously)
□ Injection (shot)
□ Other, please specify: ______________________________________________________
When did you take this medication? _____________________________________________________
Why were you given this medication? ___________________________________________________
What type of reaction did you have? (check all that apply)
Swelling
Other type of reaction – Please describe
□ Hives/Welts
□ eyes
□ Shortness of breath
□ face
or trouble breathing
□ lips
□ Wheezing
□ tongue
□ Chest tightness
□ other: (please specify)
□ Tightness in throat
□ Passed out
□ Nausea, vomiting,
diarrhea, cramping
□ Other type of rash
Please describe:
How long after taking the medication did the reaction start? _________________________________
How was the reaction treated? _________________________________________________________
Other information you want us to know: _________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Parent category: Medical