Free Allergy Check-list Form

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Allergy Check-List
Name: ______________________________________
Relationship (spouse/child etc.): ____________________
Allergy Yes/No Allergy Yes/No Allergy Yes/No
Pollens _______ Milk _______ Penicillin _______
Molds  _______ Eggs  _______ Antibiotics _______
Dust mites  _______ Fish  _______ Sulfa drugs _______
Animals _______ Crustaceans _______ Barbiturates _______
Feathers _______ Mollusks _______ Anticonvulsants _______
Insect venom _______ Wheat _______ Insulin _______
Kapok _______ Nuts _______ Novocain _______
Wool _______ Fruits _______ Iodine _______
Smoke _______ Chocolate _______ Caine anesthetics _______
Perfume _______ Sugar _______ Physical agents _______
Nitrate _______ Other:   _______    
Sulfates _______ Other:   _______