DA Form 5007A PDF: Allergy Immunotherapy Record

DA Form 5007A PDF: Allergy Immunotherapy Record – DA Form 5007A is the official U.S. Army Medical Record – Allergy Immunotherapy Record (Single Extract). It documents allergy shot (allergen immunotherapy) administration for patients receiving treatment from a single allergen extract. This specialized form ensures safe, consistent tracking of immunotherapy doses, reactions, and patient details in military healthcare settings.

It is prescribed by AR 40-66 (Medical Record Administration and Health Care Documentation) and maintained as part of the Service Treatment Record (STR).

Download DA Form 5007A PDF
Download the official fillable DA Form 5007A here

Purpose of DA Form 5007A

This form serves as a dedicated log for single-extract allergen immunotherapy. It tracks:

  • Patient identification and key medical history (e.g., systemic reactions or beta-blocker use).
  • Extract details (prescription number, content, strength/vial concentration).
  • Injection schedule, including dates, doses, arm used, reactions, and special instructions.
  • Re-evaluation due dates and technician/nursing initials for accountability.

It supports safe administration of subcutaneous immunotherapy (allergy shots), helps monitor for adverse reactions, and ensures compliance with military medical record standards. A companion form, DA Form 5007B, exists for multi-extract (double) records.

Who Uses DA Form 5007A?

  • U.S. Army healthcare providers, allergists, nurses, and medical technicians at military treatment facilities (MTFs).
  • Active-duty service members, veterans (in certain contexts), and authorized dependents receiving allergy immunotherapy.
  • Primarily for single-allergen extract therapy, common when patients are sensitive to one primary allergen or as part of a phased treatment approach.

Civilian allergy clinics may reference similar documentation practices, but this specific form is standardized for Army use.

Key Sections of the DA Form 5007A

The form includes structured fields for comprehensive documentation:

  • Patient’s Identification: Name, SSN, DOB, sex, treating facility.
  • Start Allergy Shot Date and Re-evaluation Due.
  • Prescription Number and Extract Content.
  • History of Systemic Shot Reactions? (Yes/No) with date/time.
  • On Beta Blockers? (Important for reaction risk assessment).
  • Vial/Strength Details (e.g., pnu/ml, wt/vol, AU/ml).
  • Injection Log: Date (YYYYMMDD), time, dose (ml), arm, reactions/special instructions, technician initials.
  • Signatures/Initials: Nursing personnel and technician entries for verification.

Clear, legible entries (typed or handwritten) are required for legal and medical accuracy.

How to Fill Out DA Form 5007A?

  1. Patient Info: Complete identification block fully.
  2. Extract & Prescription Details: Enter prescription number, extract content, strength, and start date.
  3. Medical History: Note any systemic reactions or beta-blocker use.
  4. Injection Record: For each visit, log date, time, dose, site (arm), any reactions, and initials.
  5. Schedule & Re-evaluation: Track build-up/maintenance phases and due dates.
  6. Review & Sign: Ensure all entries are initialed and reviewed by authorized personnel.

Always follow AR 40-66 guidelines. Use black ink for handwritten entries, and maintain the form as part of the official medical record.

Pro Tip: Many facilities now integrate electronic health records (EHR), but the paper/printed DA Form 5007A remains the official template when required.

Importance in Allergy Immunotherapy

Allergy shots are a proven long-term treatment for allergic rhinitis, asthma, and insect venom allergies. Proper documentation on forms like DA Form 5007A helps:

  • Prevent dosing errors during build-up and maintenance phases.
  • Quickly identify patterns in local or systemic reactions.
  • Support continuity of care across providers or duty stations.
  • Meet regulatory and safety standards (e.g., monitoring for anaphylaxis risk).

Accurate records are critical for patient safety in immunotherapy.

  • DA Form 5007B: For double (multi-extract) allergy immunotherapy records.
  • Other STR Forms: DA Form 5008, DD Form 2766, SF 600 (Chronological Record of Medical Care), etc.
  • Refer to AR 40-66 for full guidance on health record documentation.

Frequently Asked Questions (FAQs)

Is DA Form 5007A fillable?
Yes, the official PDF is fillable online or can be printed and completed by hand.

Where can I get the latest version?
Download directly from the official Army Publishing Directorate link provided above (FEB 2003 edition remains current as of latest references).

Who can access or file this form?
Authorized military medical personnel only. It becomes part of the protected Service Treatment Record.

Can civilians use this form?
It is designed for U.S. Army use. Civilian practices use their own or AAAAI-recommended immunotherapy forms.

For questions about your specific medical record or allergy treatment, contact your military treatment facility or healthcare provider.

This article is for informational purposes. Always consult official Army regulations (AR 40-66) and qualified medical personnel for clinical guidance.