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Immunotherapy Administration Forms

One of the benefits of these forms is to track abnormal health screens and other staff interventions that may relate to the immunotherapy injection visits. The health screen is a written or verbal evaluation of the patient’s health status. This should take place prior to administration of the immunotherapy injection.

As a members-only benefit, the forms can be edited and customized for individual practices.

Allergen Immunotherapy Administration Form: Recommended Documentation (Word)
Allergen Immunotherapy Administration Form: Recommended Documentation (PDF)

Clinical Indications for Continuation of Allergen Immunotherapy for longer than 5 years (Word)
Clinical Indications for Continuation of Allergen Immunotherapy for longer than 5 years (PDF)

Immunotherapy Administration Form for One Vial (Word)
Immunotherapy Administration Form for One Vial (PDF)

Immunotherapy Administration Form for Two Vials (Word)
Immunotherapy Administration Form for Two Vials (PDF)

Immunotherapy Administration Form for Three Vials (Word)
Immunotherapy Administration Form for Three Vials (PDF)

Health Screen Form (Word)
Health Screen Form (PDF)

Health Screen Form Landscape (Word)
Health Screen Form Landscape (PDF)

Immunotherapy Pre-Injection Questionnaire (Word)
Immunotherapy Pre-Injection Questionnaire (PDF)


By accepting the Terms of Use on preceding pages, you agree that these forms are being provided for educational and informational purposes only and are not intended to be a substitute for your independent medical judgment. The AAAAI is not liable for any decision made, or action taken by you or anyone else, in reliance upon the information contained within these forms.