Standards › Standard 53 › Forms
Form · ALR-FRM-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 53.1
Purpose
Records the allergy history for each patient: the agent, the reaction, its severity and the date of the last check.
How to complete
- Ask the patient about each agent and each past reaction.
- Record the agent, the reaction and the severity.
- Record the date of the check and who made it.
Checks
| Check | Entry |
|---|---|
| Agent (drug, product, food or other) | Yes |
| Reaction and severity | Yes |
| No known allergy (yes or no) | Yes |
| Date of last check | Yes |
| Checked by | Yes |
Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)