Fillable Allergy & Asthma Center, P.C. Current Medications, Medication

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Allergy & Asthma Center, P.C. Current Medications, Medication

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Allergy & Asthma Center, P.C.
330 S. Garden Way #150 330-C NW Elks Dr. Candice M. Rohr, M.D.
Eugene, OR 97401 Corvallis, OR 97330 Alice H. Chou, M.D.
541-485-0316 541-754-7170 Alalia W. Berry, M.D.
Fax 541-431-0317 Fax 541-758-0707
Current Medications, Medication Allergies, and Medical Problems
Patient Name
Date of Birth
DRUG ALLERGY: (There is space to document additional drug allergies on Page 2.)
I reacted to the following medication:
penicillin sulfa aspirin other (specify)_____________________________________________
Date of reaction(s)__________________________________________________________________________
I had the following reaction:
rash swelling hives trouble breathing shock
other (specify):____________________________________________________
Medication History:
List all current medications (including prescription and over-the-counter medication(s) that you are currently taking:
Name
Strength
Frequency
PHYSICIAN USE:
Date Reviewed
with Patient:
See Other Side 1 of 2
Patient’s Name_______________________________________________Birthdate____/____/____
Medical Problems:
List all past and current medical problems including surgeries and hospital admissions:
Date
Additional Drug Allergies:
Date
Drug Name
2 of 2
2019
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Completed 19 June 2021

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