Penicillin Allergy Status Penicillin Allergy Status Name Date

Penicillin Allergy Status Penicillin Allergy Status Name: _____________________________ Date of Birth: _______________________ Date of Evaluation: ___________________ Name: _____________________________ Date of Birth: _______________________ Date of Evaluation: ___________________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because: I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because: Evaluator: __________________________ Evaluator: __________________________ Penicillin Allergy Status Name: _____________________________ Date of Birth: _______________________ Date of Evaluation: ___________________ Name: _______________ Date of Birth: ____________ Date of Evaluation: __________ I had a penicillin allergy evaluation, and I am NOT allergic to penicillins because: Evaluator: __________________________ Evaluator: _____________ This resource is part of the Penicillin Allergy Assessment Toolkit, a collaboration of the UNC Medical Center’s Carolina Antimicrobial Stewardship Program, the UNC Division of Rheumatology, Allergy & Immunology, and the UNC Institute for Healthcare Quality Improvement. See additional resources at https: //www. med. unc. edu/casp/educational-resources/.