DA Form 5007B: Allergy Immunotherapy Record (Double Extract)

DA Form 5007B: Allergy Immunotherapy Record (Double Extract) – DA Form 5007B is a specialized U.S. Army medical record form used to document allergy immunotherapy (allergy shots) involving double allergen extracts. It ensures safe, standardized tracking of treatments for service members undergoing hyposensitization therapy.

This form supports military healthcare providers in maintaining detailed records of doses, reactions, and patient monitoring, as required by Army Regulation (AR) 40-66, Medical Record Administration and Healthcare Documentation.

Download the Official DA Form 5007B Here:
DA Form 5007B PDF

What Is DA Form 5007B?

DA Form 5007B, titled Medical Record – Allergy Immunotherapy Record (Double Extract), is the official Department of the Army form for documenting allergy shots when two allergen extracts are administered. It is the companion to DA Form 5007A (Single Extract).

The form is used primarily in military treatment facilities (MTFs) for patients receiving subcutaneous immunotherapy for allergic conditions such as allergic rhinitis, insect venom allergies, or other sensitivities. It provides a structured log for each injection, including date, time, dose, arm/site, reactions, and technician initials.

Key sections typically include:

  • Patient identification (name, SSN/DOB, facility).
  • Prescription number and extract content details.
  • Re-evaluation due dates.
  • History of systemic reactions and beta-blocker use.
  • Dual columns for tracking two extracts (dose, reactions/special instructions, initials).

The current version is dated FEB 2003, and older versions (e.g., NOV 1991) are obsolete.

Purpose of the Allergy Immunotherapy Record

The primary purpose of DA Form 5007B is to ensure patient safety and continuity of care during allergy immunotherapy. Allergy shots involve gradually increasing doses of allergens to build tolerance, which carries risks of local or systemic reactions.

In the U.S. Army context, this form:

  • Documents each injection accurately for quality assurance and medical review.
  • Tracks potential adverse reactions for prompt intervention.
  • Supports standardization through systems like the U.S. Army Centralized Allergen Extract Laboratory (USACAEL/ELMS).
  • Facilitates continuity when service members transfer between duty stations or deploy.

Proper use aligns with AR 40-66 guidelines for service treatment records.

Who Uses DA Form 5007B?

This form is used by:

  • Army allergists and immunology specialists.
  • Nursing personnel and allergy technicians administering shots.
  • Primary care providers in allergy extender clinics at smaller bases.
  • Facilities involved in military allergy care, including those supporting TRICARE beneficiaries.

It is part of the service treatment record and may be filed or integrated with electronic health records like AHLTA or MHS GENESIS where applicable.

Note for Civilians: While primarily a military form, similar documentation principles apply in civilian allergy practices. Active-duty personnel, veterans, or dependents receiving care in military facilities will encounter this form.

How to Fill Out DA Form 5007B: Step-by-Step Guide?

  1. Patient Identification — Enter full name (last, first, middle), SSN or DoD ID, DOB, sex, and treating facility at the top.
  2. Extract and Prescription Details — Record prescription number(s), extract content (allergens, concentrations), and re-evaluation due dates.
  3. Medical History Flags — Check boxes for history of systemic shot reactions and current beta-blocker use (important for anaphylaxis risk).
  4. Injection Log — For each visit:
    • Date and time (YYYYMMDD format).
    • Dose (volume and dilution for each extract).
    • Arm/site of injection.
    • Reactions or special instructions.
    • Technician/nurse initials.
  5. Dual Columns — Use the side-by-side layout for the two extracts in double therapy.

Always use black or blue ink for handwritten entries. Follow AR 40-66 for approved abbreviations. Electronic documentation may supplement or replace the paper form in modern systems.

Tip: Double-check extract details against the prescription to prevent administration errors.

Importance of Accurate Documentation in Allergy Immunotherapy

Accurate records on DA Form 5007B help:

  • Monitor dose progression and adjustments.
  • Identify patterns in local (redness, swelling) or systemic reactions (e.g., hives, breathing issues).
  • Support medical decisions, such as dose reductions or temporary holds.
  • Ensure compliance with safety standards for immunotherapy.

In military settings, this documentation is critical due to frequent relocations, deployments, and operational demands where uninterrupted therapy may not always be feasible.

  • DA Form 5007A — For single extract immunotherapy.
  • AR 40-66 — Governs medical record administration.
  • SF 600 — Often used for additional progress notes.
  • USACAEL/ELMS for standardized extract preparation.

For the latest official versions, visit the Army Publishing Directorate (armypubs.army.mil).

Download and Access DA Form 5007B

Official Download Link:
DA Form 5007B – Allergy Immunotherapy Record (Double Extract)

This fillable PDF is available through Army eForms. Authorized personnel can access it via official military portals.

This article is for informational purposes and references publicly available U.S. Army resources. Always consult your military healthcare provider or unit medical personnel for specific guidance on medical records and allergy treatment.