药物过敏筛查.docxVIP

药物过敏筛查

体检表格-药物过敏筛查

姓名:_______________________年龄:_________________性别:_________________

过敏史:

请在下方的表格中勾选适用的项目(√)，并根据具体情况提供详细的病史和症状描述。如果你不确定是否有过敏反应，请在每个选项下写上不确定。

|------------------------------|----------------|-------------------------|

|药物名称|曾有过敏反应吗？|过敏症状描述|

|------------------------------|----------------|-------------------------|

|非处方药|||

|------------------------------|----------------|-------------------------|

|处方药|||

|------------------------------|----------------|-------------------------|

|草药|||

|------------------------------|----------------|-------------------------|

在下方提供详细的过敏症状描述:

(请尽可能详细描述症状，包括身体部位、疼痛程度、出现的频率以及与时间、饮食等的关联性)

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