Prescribing Physician:
Address:
Patient Name:
Date of Birth:
Patient Number:
Telephone Number:
Diagnosis:
Call to reorder when next to last AI given. Fax this form to FAX number. This will be
required before any new extract can be prepared.
Best Baseline Peak Flow: ___________________
Baseline Blood Pressure: ___________________
Dilution
Color
Telephone: Phone:
Fax: E-mail:
Immunotherapy Vaccine Administration Form
1:1,000,000
Peach
#7
1:100,000
Pink
#6
1:10,000 (v/v)
Silver
#5
1:1000 (v/v)
Green
#4
1:100 (v/v)
Blue
#3
1:10 (v/v)
Yellow
#2
Maintenance
1:1 (v/v) Red
#1
Vial D Expiration date(s)
____/____/___
____/___/__
____/____/___
____/____/___
____/____/___
____/____/____
____/____/___
Vial E Expiration date (s)
____/____/___
____/___/__
____/____/___
____/____/___
____/____/___
____/____/____
____/____/___
Vial F Expiration date (s)
____/____/___
____/___/__
____/____/___
____/____/___
____/____/___
____/____/____
____/____/___
Vaccine content Abbreviations*
Tree: T
Mold: M
Grass: G
Cat: C
Weed: W
Dog: D
Ragweed: R
Cockroach: Cr
Mixture: Mx
Dust Mite: Dm
Allergy E
prepared:_________
Made by:_________
Left office: ________
Total Units: _______
INJECTION INTERVAL IS EVERY_________DAYS _________WEEKS
VIAL D:
Date
Time
Health
AntiPeak Flow
screen histamine
2
abnorm taken?
Pre
Post
al1
Arm
Vial E:
Vial
Dilution
Delivered
Volume
Reaction
3
Vial F:
Arm
Delivered
Volume
3
Reaction
Arm
Vial Dilution Delivered Reaction3
Volume
Injector
Initials
Vial
Dilution
1. ____/____/____
_______
Y
N
Y N
____________
____________
________
____________
________
________
____________
L
L
________ ____________ _______
________
R
R
________
Y N
L
L
________
N
R
R
________
Y
L
L
________
_______
R
R
________
2. ____/____/____
________
________ ____________ _______
3. ____/____/____
_______
Y
N
Y N
R
L
________
________
____________
R
L
________
________
____________
R
L
________
________ ____________ _______
4. ____/____/____
_______
Y
N
Y N
R
L
________
________
____________
R
L
________
________
____________
R
L
________
________ ____________ _______
5. ____/____/____
_______
Y
N
Y N
R
L
________
________
____________
R
L
________
________
____________
R
L
________
________ ____________ _______
6. ____/____/____
_______
Y
N
Y N
R
L
________
________
____________
R
L
________
________
____________
R
L
________
7. ____/____/____
_______
Y
N
Y N
R
L
________
________
____________
R
L
________
________
____________
R
L
________
8. ____/____/____
_______
Y
N
Y N
R
L
________
________
____________
R
L
________
________
____________
R
L
________
________ ____________ _______
________ _______
____________
________ ____________ _______
L
________
________
____________
R
L
________
________
____________
R
L
________
________ ____________ _______
L
________
________
____________
R
L
________
________
____________
R
L
________
________ ____________
9. ____/____/____
_______
Y
N
Y N
R
10. ____/____/____
_______
Y
N
Y N
R
1. Health screen refers to either a written or verbal interview of the patient prior to the administration of the allergy injection regarding: the presence of increased allergy or asthma symptoms
or symptoms of respiratory tract infection, beta-blocker use, change in health status (including pregnancy) or adverse reaction to previous injection. A yes answer to this health screen may
require further evaluation (see health screen record on back page).
2. Antihistamine use: to improve consistency in interpretation of reactions it should be noted if the patient has taken an antihistamine on injection days. Physician may also request that
antihistamines be taken consistently on injection days: recommended: Y N
Vial D ( # vials sent = _____)
Conc
Color
Volume
Projected Build-up Schedule
Vial E ( # vials sent = _____)
Conc
Color
Volume
Vial F ( # vials sent = _____)
Conc
Color
Volume
3. Reaction: refers to either immediate or delayed systemic
or local reactions. Local reactions (noted as LR) can be
reported in millimeters as the longest diameter of wheal and erythema.. The details of the symptoms and treatment of a systemic reaction (noted as SR) would be recorded elsewhere in the
medical record.
Injector signature
Initials
Days since last AI
≤ 1 ½ x interval: continue to increase
≤ 2 x interval: repeat previous dose
≤ 3x interval: reduce by 25%
≤ 4x interval: reduce by 50%
> 4x interval: see Dr. Wallace
(See enclosed sheet for examples)
Locals
>2.5 cm + last 24 hours:
repeat dose
>6 cm, go back one dose