Penicillin Allergy Questionnaire

Note

Review questions below with patient and call ASP team afterwards

Question 1

Who told you that you have a pencillin allergy (more than one may apply)?

Question 2

Have you ever had a penicillin allergy skin test?

Question 3

If YES to #2, the test result was:

Question 4

When did you last receive penicillin?

Question 5

When was your last allergic reaction to pencillin?

Question 6

What was the nature of your reaction to penicillin?

Question 7

How quickly did the reaction develop after the penicillin was taken?

Question 8

Have you ever been diagnosed with Stevens Johnsons syndrome or toxic epidermal necrolysis related to penicillin?

(Prompt for clarification: skin peels off; involvement of mouth, anus, eyes; requires hospitalization or ICU stay)

After Questionnaire:

Call ASP Team: Monday to Friday 8am - 5pm