DA Form 5007a "Medical Record - Allergy Immunotherapy Record (Single Extract)"

What Is DA Form 5007a?

This is a military form that was released by the U.S. Department of the Army (DA) on February 1, 2003. The form, often mistakenly referred to as the DD Form 5007a, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

Form Details:

  • A 1-page document available for download in PDF;
  • The latest version available from the Army Publishing Directorate;
  • Editable, free, and easy to use;

Download an up-to-date fillable DA Form 5007a down below in PDF format or browse hundreds of other DA Forms stored in our online database.

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Download DA Form 5007a "Medical Record - Allergy Immunotherapy Record (Single Extract)"

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SINGLE
ALLERGY IMMUNOTHERAPY RECORD
MEDICAL RECORD
EXTRACT
For use of this form, see AR 40-66; the proponent agency is the TSG.
START ALLERGY SHOT DATE
RE-EVALUATION DUE
PRESCRIPTION NUMBER
EXTRACT CONTENT
HISTORY OF SYSTEMIC SHOT REACTIONS?
YES
ON BETA BLOCKERS?
YES NO
DATE
STRENGTH
SCHEDULE
DOSE
TECH
TIME
VIAL #
ARM
REACTIONS OR SPECIAL INSTRUCTIONS
(YYYYMMDD)
(pnu/ml, wt/vol, AU/ml)
A, B, C, D, E, F
(ml)
INITIALS
PATIENT'S IDENTIFICATION
(For typed or written entries give
NURSING PERSONNEL INITIALS
Name--last, first, middle,
NAME
INITIALS NAME
INITIALS
SSN; DOB; sex; treating facility)
DA FORM 5007A-R, NOV 91, IS OBSOLETE.
APD LC v1.02ES
DA FORM 5007A, FEB 2003
SINGLE
ALLERGY IMMUNOTHERAPY RECORD
MEDICAL RECORD
EXTRACT
For use of this form, see AR 40-66; the proponent agency is the TSG.
START ALLERGY SHOT DATE
RE-EVALUATION DUE
PRESCRIPTION NUMBER
EXTRACT CONTENT
HISTORY OF SYSTEMIC SHOT REACTIONS?
YES
ON BETA BLOCKERS?
YES NO
DATE
STRENGTH
SCHEDULE
DOSE
TECH
TIME
VIAL #
ARM
REACTIONS OR SPECIAL INSTRUCTIONS
(YYYYMMDD)
(pnu/ml, wt/vol, AU/ml)
A, B, C, D, E, F
(ml)
INITIALS
PATIENT'S IDENTIFICATION
(For typed or written entries give
NURSING PERSONNEL INITIALS
Name--last, first, middle,
NAME
INITIALS NAME
INITIALS
SSN; DOB; sex; treating facility)
DA FORM 5007A-R, NOV 91, IS OBSOLETE.
APD LC v1.02ES
DA FORM 5007A, FEB 2003