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Review questions below with patient and call ASP team afterwards
Who told you that you have a pencillin allergy (more than one may apply)?
Parents or relatives
Physician
Nurse
Pharmacist
I don't know
No one told me
I know I have an allergy
Have you ever had a penicillin allergy skin test?
Yes => Go to #3
No => Go to #4
If YES to #2, the test result was:
Positive
Negative
When did you last receive penicillin?
Never
> 10 years ago
1-10 years ago
Days to months ago
When was your last allergic reaction to pencillin?
What was the nature of your reaction to penicillin?
Rash
Anaphylactic reaction (BP problems, difficulty breathing, tongue/lip swelling)
Feeling jittery
Dizziness
Tingling
Fatigue
Nausea/vomiting
Diarrhea
Heartburn/abdominal discomfort
Chest pain/palpitations
Other (describe)
How quickly did the reaction develop after the penicillin was taken?
Minutes to hours
Hours to days
More than 1 week
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)
Yes
No
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