Name Date of Birth Date of Evaluation I had a penicillin allergy evaluation and I am NOT ID: 909691
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Slide1
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
Penicillin
Allergy Status
Name
: _____________________________Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because:Evaluator: __________________________
This resource is part of the Penicillin Allergy Assessment Toolkit, a collaboration of the UNC Medical Center’s Carolina Antimicrobial Stewardship Program, the UNC Division of Rheumatology, Allergy & Immunology, and the UNC Institute for Healthcare Quality Improvement.
See additional resources
at
https://www.med.unc.edu/casp/educational-resources
/
.