Questionnaire about allergies
In recent years, the number of people with various allergies is increasing.
There are also reports of shock caused by products such as gloves and drugs usedduring treatment.
Please answer the following questions so that you can undergo surgery and treatment ina safe environment.
* If you answered "yes" to the applicable item in the thick line, please fill in therequired items.
For staff only

Patient ID

year/month/day

Name of patient

・・

・・

・・

・・

・・

・・

・・

Confirmer
Date；

Questionnaire
1）Have you had any allergic
reactions to a medicine or
intravenous feeding,disinfectant?
□No

□Yes

year

month
/

day

Writer；□Patient/□Amanuensis(For medical staff only)＊Please fill in if you answered "yes"additional information

・Please tell me the name of medicine andinjection medicine, disinfectant.
□Alcohol□Iodine□Antibiotic agents（□Lidocaine□disinfectant（□Oral medicine（□Other（□unknown））））

・Please tell me what kind of symptoms youhad.（ex. Itchiness , Hives）（）
2） Have you had any allergic
reactions to a food?
□No

□Yes

・Please tell me the kind of the food.
□kiwii □mango □peach □banana□chestnut□tomato□egg□milk□wheat□soba□crab□shrimp□peanuts□soy□other（）

・To the following ☑ allergy tolatex doubt group "II"・Please tell me what kind of symptoms you had.
（）
・Please tell me what kind of symptoms you had.
3） Have you had any allergic
reactions to metal objects such （）
as watches, necklaces, rings,
earrings, and glasses?

□No

□Yes

・Please tell me the name of products.
4） Has your skin turned red
because of a compress or tape? （）・□unknown
□No

□Yes

5）Have you ever been toldthat you are allergic to latex?
□No

□Yes

・Please tell me what kind of symptoms you had.
（）

・Have you ever been told that you are positive
for latex antigen-specific IgE antibodies?
□No

□Yes

・"Yes" is suspected of latex
allergy Group "I"＊Please fill in the back side

Allergy information sharing procedure pg.4

Date / Sign of the staff

Questionnaire＊Please fill in if you answered "yes"(For medical staff only)
additional information

Date / Sign of the staff6）Has your skin turned red
・ Please tell me the kind of the rubber
because of a rubber product? product.
□No

□Yes

（

）・□unknown

・Please tell me what kind of symptoms you had. ・When an immediate allergy
comes out; allergy to latex（）
doubt group "I"・The symptom existence group "III"７）Are you doing work to treat ・Please tell me the kind of work.
a rubber product (rubber□Medical related □Hairdresser
gloves, tire) now or before?
□Cleaning related□Rubber product manufacturing□No□Yes□Other（）
・To the following ☑ allergy tolatex doubt group "II"８） Do you have any otherallergies?
□No

□Yes

・Please check the corresponding items.
□sunlight□Other（□Tick□pollen）・Please tell me what kind of symptoms you
have.
（
）
９）Have you ever experienced
an unexplained shock? (ex.
pallor of the face, decreased
blood pressure, loss of
consciousness)
□No
□Yes

・If you experience a shock of
unknown cause, Latex Allergy
Suspicious Group "III"・Please check in the applicable name of10） Have you suffered from thediseasedisease listed in the right-hand□Spina bifida □Osteomyelitis
column?
□Bronchial asthma due to rubber□No□Yes□Atopic dermatitis□Bronchial asthma□Contact dermatitis

・☑ on the left is Latex Allergy
Suspicious Group "I"・☑ on the left is Latex Allergy
Suspicious Group "Ⅱ"

11）Have you ever been
anesthetized for surgery or
dental treatment?
□No

□Yes

12） Have you had any
symptoms because ofanesthesia?
□No・What kind of anesthesia you received?
□General anesthesia□Lumbar spinal anesthesia□Local anesthesia□unknown
・Please tell me what kind of symptoms you
had.
（
）

□Yes

13）Have you ever had a blood ・Have you ever had any symptoms because
transfusion?
of a blood transfusion?
□No
□Yes
□No
□Yes
・Please tell me what kind of symptoms you
had.
（）＊Thank you for input.
If you have any questions, please ask.

2015/10/1 Hyogo Rehabilitation Center Hospital

Allergy information sharing procedure pg.5