Dr's Name___________________________________
Dr's Phone___________________________________
Patient Name_________________________________________
Allergy Extract Administration Record at Messiah College Health Center
ALLERGEN:____________________________________________
ALLERGEN:____________________________________________
Begin bottle #_________ at ________ml. Advance dose by _________ ml.
q_________wk(s) until maintenance level is _________ml. q_________wk(s). See
separate order for reducing doses for missed injections as supplied by student's
physician.
Begin bottle #_________ at ________ml. Advance dose by _________ ml.
q_________wk(s) until maintenance level is _________ml. q_________wk(s). See
separate order for reducing doses for missed injections as supplied by student's
physician.
_____________________________________________________________
_____________________________________________________________
_______________________________________________________
________________________________________________________________
________________________________________________________________
_______________________________________________________
Date
Initials
Arm
R or L
Dilution
Bottle
#/Color
Dose
Peak
Flow
Reaction
Date
Initials
Arm
Dilution
R or L
Bottle #/Color
Dose
Peak
Flow
Reaction