o Muskegon o Grand Haven o Grand Rapids 1675 Leahy Street, Suite 120 923 S . Beechtree Street, Suite 9 150 Jefferson Avenue SE, Suite 110 Muskegon, MI 49442 Grand Haven, MI 49417 Grand Rapids, MI 49503 Phone: 231 .728 .4915 Phone: 616 .847 .6233 Phone: 616 .685 .3150 Fax: 231 .728 .5980 Fax: 616 .847 .6959 Fax: 616 .685 .3155
Name: Date of Birth:
Date:
1. Have you ever had a severe allergic reaction to latex devices/products? ...... o Yes o No If yes, under what circumstances did it occur? 2. Have you ever been told by a doctor that you have an allergy to any latex product?...... o Yes o No If yes, to what specifically did the doctor say you were allergic to? 3. Do you have an congenital abnormalities (i.e. spina bifida, myeloma, myelodysplasia)? ...... o Yes o No 4. Have you had a reaction to the following personal sources of latex? Balloons...... o Yes o No Dental cofferdams ...... o Yes o No Rubber gloves...... o Yes o No Erasers...... o Yes o No Hot water bottles...... o Yes o No Face masks ...... o Yes o No Rubber bands, balls...... o Yes o No Elastic bandages ...... o Yes o No Foam pillows...... o Yes o No Cuffs, elastic waistbands ...... o Yes o No Baby bottles, nipples...... o Yes o No Ostomy bags ...... o Yes o No Pacifiers, teething rings...... o Yes o No Shoewear...... o Yes o No Belts, bras, suspenders...... o Yes o No Other: Latex birth control devices...... o Yes o No 5. After handling latex products, have you experienced any of the following? Difficulty breathing...... o Yes o No Redness...... o Yes o No Chapping or “cracking of hands”...... o Yes o No Swelling ...... o Yes o No Runny nose/congestion...... o Yes o No Hives...... o Yes o No Itching (eg . hands, eyes)...... o Yes o No Other: 6. Do you have a history of the following? Contact dermatitis...... o Yes o No Eczema...... o Yes o No Asthma ...... o Yes o No Autoimmune disease (e .g . Lupus)...... o Yes o No Hay fever...... o Yes o No 7. Do you have any food allergies? o Yes o No If yes, are you allergic to any of the following? o Bananas ...... o Recent Onset o Long-standing o Chestnuts...... o Recent Onset o Long-standing o Avocados...... o Recent Onset o Long-standing o Peaches...... o Recent Onset o Long-standing o Potatoes ...... o Recent Onset o Long-standing o Papaya...... o Recent Onset o Long-standing o Tomatoes...... o Recent Onset o Long-standing o Other: o Kiwis...... o Recent Onset o Long-standing o Recent Onset o Long-standing If yes, describe the reaction: 8. Have you had any previous surgeries? ...... o Yes o No How many before 1 year old? Types of surgical procedures: 9. Have you had extensive dental work? ...... o Yes o No Define extensive when exposure occurred: 10. Does your occupation involve contact with products containing latex? ...... o Yes o No If yes, which products?
NOTE: This assessment is not intended to be all inclusive . Copyright © July 2013 Mercy Health Form 185C