Healthcare Provider Intolerance Assessment Form
Please complete this form to help us understand any intolerances or sensitivities you may have to healthcare providers, treatments, or environments.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any known intolerances or sensitivities to healthcare providers, treatments, or clinical environments?
*
Yes
No
Please indicate any specific intolerances or sensitivities you have experienced. (Select all that apply)
*
Latex
Medications (e.g., antibiotics, anesthesia)
Disinfectants or cleaning products
Personal protective equipment (e.g., gloves, masks)
Hospital food or drink
Other (please specify)
Please rate the severity of your reactions to the following using the scale below.
*
Rows
Never
Mild
Moderate
Severe
Latex
1
2
3
4
Medications
5
6
7
8
Disinfectants
9
10
11
12
Personal protective equipment
13
14
15
16
Hospital food/drink
17
18
19
20
Please describe the symptoms you experience during a reaction.
*
Have you ever required emergency medical attention due to an intolerance or sensitivity?
*
Yes
No
Please list any current medications or ongoing treatments.
Do you have any chronic health conditions?
*
Yes
No
If yes, please specify your chronic health conditions.
Is there any additional information you would like to share regarding your intolerances or sensitivities?
Submit Assessment
Should be Empty: