Penicillin Allergy Questionnaire Your name First Last Your date of birthDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Have you ever been told that you have a penicillin allergy? Yes, I have No, I haven’t That’s all we need to know! Please click on the submit button to send your response to us.It is estimated that over 5 million people in the UK are incorrectly labelled as having a penicillin allergy.These people unnecessarily miss out on the best and safest treatments for common bacterial infections. These include chest, throat, sinus, inner ear and skin infections. They also have an increased risk of complex, prolonged hospital admissions and severe infections.By completing this simple allergy screening questionnaire it is possible to identify if you are not truly allergic to penicillin. You can then discuss removing this label with your GP or Pharmacist. These patients will then be able to use penicillin based antibiotics to treat bacterial infections as appropriate and will avoid the significant risks associated with being truly penicillin allergic.Tell us about your suspected allergyWas this suspected allergy within the last 10 years? Yes No Did you experience breathlessness, wheezing, lip/tongue swelling or collapse? Yes No Did you experience a severe blistering or peeling skin reaction? Yes No Did you require any treatment (e.g., antihistamines) for your reaction? Yes No Did you experience any of these non-allergic symptoms?Nausea, vomiting, mild abdominal pain? Yes No Headache, mild confusion, changes in your mood? Yes No Thrush or C.difficile bowel infection after taking penicillin? Yes No That’s all we need to know! Please click on the submit button to send your response to us.
