Allergy Immunotherapy Maintenance Shot Record Form
Record details of each allergy immunotherapy maintenance injection accurately and completely.
Patient Name
*
First Name
Last Name
Date and Time of Injection
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Clinic/Location
*
Allergen/Vial Information
*
Dose Administered (mL)
*
Injection Site
*
Left Arm
Right Arm
Left Thigh
Right Thigh
Other
Shot Status
*
Given as Scheduled
Held (Medical Reason)
Held (Patient Request)
Pre-Shot Symptom Screening
*
No symptoms
Recent illness
Wheezing or respiratory symptoms
Fever
Other (describe below)
Post-Shot Reaction/Observation
*
No reaction
Local redness/swelling
Itching
Systemic symptoms (describe below)
Staff Initials/Signature
*
Submit Record
Submit Record
Should be Empty: