Latex Allergy Form
CNM Health Occupations Department
Latex Allergy Assessment
(To be attached to Student Physical Form and filled out by the student who then gives it to the health practitioner completing the physical exam)
Name_____________________ Date_____________
1. After a medical or dental procedure, have you ever had any of the following
a. Rash ______Yes _____No
b. Hives ______Yes _____No
c. Swelling ______Yes _____No
d. Shortness of breath ______Yes _____No
2. Have you ever had a rash on your hands that lasted greater than a week? ______Yes _____No
a. If yes, do you know what it was from?
______________________________________________________________________________________________________________________________
3. After coming in contact with any latex or rubber product (e.g.: balloons, gloves, condom, diaphragms, etc.) have you experienced any of the following?
a. Rash ______Yes _____No
b. Hives ______Yes _____No
c. Swelling ______Yes _____No
d. Itching ______Yes _____No
e. Runny nose ______Yes _____No
f. Eye irritation ______Yes _____No
g. Wheezing or asthma ______Yes _____No
4. Has a physician ever told you that you are allergic to rubber or latex? ______Yes _____No
If yes, what kind of treatment did you receive? ______________________________________________________________________________________________________________________________
5. Do you/did you use gloves or any rubber/latex product in previous occupation or jobs?
______Yes _____No
If yes, what products were you exposed to? ____________________________________________________________________________________________________________________________________
6. Do you have any food allergies?
______Yes _____No
7. If yes, are you allergic to any of the following?
Recent onset long standing
Bananas __________ __________
Avocados __________ __________
Pineapple __________ __________
Kiwis __________ __________
Chestnuts __________ __________
Passion Fruit __________ __________
Other __________ __________ __________
Describe the reaction: ______________________________________________________________________________________________________________________________
8. Do you have any congenital abnormalities (spinabifida, Myeloma, Myelodysplasis)?
Yes_______ No________
9. Do you have history of the following?
a. Contact dermatitis ______Yes _____No
b. Asthma ______Yes _____No
c. Hay fever ______Yes _____No
d. Eczema ______Yes _____No
e. Autoimmune disease ______Yes _____No
_________________________________ ______________________
Student Signature/Date Physician signature/Date
Please make a copy for your own records
August 2002
