Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

• Beta-Blockers (heart disease, high blood pressure, glaucoma)
Acebutolol Carvedilol Pindolol Atenolol
Laberalol Propranolol Betaxolol Metoprolol
Timolol Bisoprolol Nadolol Cartcolol
• ACE inhibitors / Angiotensis Receptor Blockers (High blood pressure, kidney)
Benazepril Lisinopril Ranipril Captopril
Losartan Trandolapril Enalapril Moexipril
Fosinopril Quinapril
• Corticosteroids (pills, liquids, or shots)
Betamethosone Hydrocortisone Prednisone Cortisone
Triamcinolone Methylprednisolones Dexamethaxone Prednisolons
DRUG ALLERGIES
Please list any allergies or adverse reactions to any medications that you may have:
GENERAL QUESTIONS
Please circle the best answer for each of these questions concerning your allergy shots:
1. During the last year my symptoms on allergy shots have:
a) worsened b) stayed the same c) improved d) disappeared completely e) don't know
2. How many times have you visited a health care provider for allergy problems in the
last year (not including allergy shot visits)?
0 1 2 3 4 5 6 7 8 9 10 >10
3. How many workdays were missed during the last year that were all or partly due to
allergies?
0 1 2 3 4 5 6 7 8 9 10 >10
4. Comments:____________________________________________________________________________
_________________________________________________________________________________________
Reviewed by Physician:_____________________________
Date:___________________________