Allergy history

Texas Sinus Center
ALLERGY TESTING INFORMATION
1. On the day of testing please wear a short-sleeved shirt that can be pushed up comfortably to your shoulder. Allow 1-2 hours for your test session. You will need to stay on the premises during this time. Please do not bring children to your appointment.
2. Remember to STOP TAKING ANTIHISTAMINES and DECONGESTANTS at least 5 days before your appointment (See attachment for stop times concerning individual meds.). Please discontinue Astelin nasal spray 24 hours prior to testing. Please inform the staff of any medications you are taking that would prevent you from being tested (See attached forms). 3. Allergy testing is done on your lower forearm with tiny applicators that abrade the surface of the skin. Each device contains fluid (extracts) from native Texas allergens. If you are allergic to any of the antigens, you will get a raised, itchy bump that resembles a large mosquito bite.
4. Insurance pre-certification will be done prior to your appointment. Patients will be informed of charges not covered by insurance and will be responsible for all charges not covered at the time of testing.
I, _____________________________, have read and understand the above
Signature/Date_________________________/___________ Witness _________________________________________ Texas Sinus Center
ALLERGY HISTORY
Instructions
Carefully complete in full. Accuracy and thoroughness are essential. Print all answers.
Relate all answers to your own experiences, not to previous advice on skin tests. This
form must be completed prior to seeing the practitioner. All information will be
considered confidential.
Name_____________________________________DOB_____/______/_____Age_____ State problems you wish to discuss:
□ Food Sensitivities □ Sinus Infections When did it begin? ______Worse at night/day? _____ Check months most severe:

□ All months
□ January
Check items that affect your symptoms
Are your symptoms made worse by: □ Wind □ Air-conditioning □ Travel/Vacations Previous Allergy Treatment
□ No If yes, by whom? _________________________ Last Date Tested: _________________
2. Have you ever been treated with Allergy Shots? If yes, what were you treated for? □ Grass pollens 4. Did the Allergy Shots help you? □ Yes 5. What years were the shots taken? ____________ to _____________ Medical History
□ Asthma If so, ever hospitalized for asthma: _______________________
□ High blood pressure
What medication do you take to control it? _____________________________ □ Recurrent Ear infections □ Recurrent sinus infections □ Repeated tonsillitis
□ Cancer: What type; ____________________________________
□ Heart trouble: What kind? _______________________________
□ Diabetes: Type I or II
Are you pregnant now? □Yes □ No
Last Period Date: ________
Actively trying to conceive? □Yes □ No
Other Medical conditions not mentioned: ____________________________________
________________________________________________________________________
________________________________________________________________________
Pets Which of these do you have as pets or exposed to:
Is your condition worse around pets? □Yes □No Specify: ____________________________________________________ Allergies to Medications: _______________________________________
Patient Signature_________________________________________________________
Practitioners Signature_________________________________Date________________ Texas Sinus Center
Skin Testing Information and Consent
1. Skin Testing
An allergy skin test is used to identify the substances that are causing your allergy symptoms. We will
apply several extracts of common allergens to the skin and observe for a reaction. The reactions are then
graded and confirmatory intradermal testing may be performed. This involves injecting a small amount
of extract under the skin of the upper arm. We then obeserve the reaction and record the results.
2. Risks of Skin Testing
Bleeding and infection may occur due to the abrading of the skin. Any time the skin integrity is broken it puts one at risk for infection. However, this is a very rare occurrence. The antigens
used for testing are sterile and approved by the FDA. Occasionally, skin testing can trigger a severe
allergic reaction requiring treatment with medications available in our office and/or the ER. Patients
with asthma are at increased risk for triggering an asthma attack during testing. You should not undergo
testing if you feel that your allergy or asthma symptoms are currently under poor control.
3. Contra Indications to Skin Testing
Woman who are pregnant or anyone who is currently taking Beta-blocker medications should not have skin testing done. If you have taken any antihistamines, on the list provided, within the specified
time prior to your appointment testing will not be performed. These medications interfere with the
immune process needed for a reliable test. Please be sure to inform us of all medications you have taken
before the skin test is applied. (You must discontinue Atarax (Hydroxyzine), Xyzal and Zyrtec a
minimum of 5 days prior to testing). Patients on Beta-blockers will NOT be skin tested because death
may occur. If you are not sure if you are taking an antihistamine or beta-blocker, please ask your
pharmacist.
4. Consent for Skin Testing
I understand the risks and benefits of skin testing and all questions have been answered to my satisfaction. I consent to skin testing and understand that I am financially responsible for all charges not covered by my medical insurance. I understand that the fees incurred for allergy testing will be my responsibility to the extent that insurance deductible, co-payments, and allowables, may leave a balance. It is also my understanding that the insurance claims will be filed first, with the balance being billed to me following processing of the insurance claim(s). NAME (Print) ___________________________________ SIGNATURE____________________________________ *** VERY IMPORTANT ***
LET US KNOW IF YOU ARE TAKING ANY OF THE FOLLOWING
MEDICATIONS
BETA BLOCKERS
TOPICAL BETA BLOCKERS
Corzide (nadolol) Inderide (propanolol)Inderide LA (propanolol) TRICYCLIC ANTIDEPRESSANTS
MONOAMINE OXIDASE
INHIBITORS
Marplan (isocarboxazid) Nardil (pheneizine sulfate) Parnate (tranlcypromine sulfate) PLEASE DO NOT STOP ANY PRESCRIPTION MEDICATION WITHOUT
DISCUSSING IT WITH THE DOCTOR FIRST.
ANTIHISTAMINES
YOU MUST STOP TAKING All ANTIHISTAMINES 5 DAYS PRIOR TO THE
ALLERGY TESTING.
PRESCRIPTION
Allegra (fexofenadine)
Allegra D (fexofenadine)
Atarax (hydroxyzine)
Benadryl prescription (diphenhydramine)
Claritin D (loratidine)
Clarinex (desloratadine)
Periactin (cyproheptadine)
Phenergan (promethazine)
Vistaril (hydroxyzine)
Zyrtec (cetirizine)
Xyzal (levocetirizine)
Patanase (olopatadine hydrochloride)
OVER-THE-COUNTER
Benadryl (liquid or capsule form)
Dimetapp (brompheniramine maleate)
Chlor Trimeton
Chlorpheniramine maleate
Claritin (loratidine)
Dexchlorpheniramine maleate
Diphenhydramine hydrochloride
Promethazine HCL
Tavist, Tavist D (clemastine fumarate)
Triaminic
Tripelennamine citrate or hydrochloride
Trimeprazine tartrate
Tripolidine hydrochloride
Tylenol PM
Tylenol Allergy & Sinus
Antacids (Tagamet, Zantac, Pepcid, Pepcid AC, Axid)
Allergy eye drops (livostin, Patanol, etc.)
ALL VITAMINS AND HERBAL MEDICINES NEED TO BE DISCUSSED & STOPPED PRIOR TO TESTING ESPECIALLY WATCH FOR VITAMIN C, ST. JOHN’S WORT AND STOP ALL HERBAL ALLERGY SUPPLEMENTS 5 DAYS PRIOR TO TESTING.
HOW CAN YOUR ALLERGIES BE TREATED?
The best treatment for allergies is to identify the offending substances then
carefully avoid exposure to them. This can be very effective for allergies to
things like pets, dust mites and foods but is not possible for some allergies
such as pollens, and mold spores.
Medications such as antihistamines, oral decongestants, nasal sprays, and bronchodilators may be effective in controlling your allergic symptoms. Medications may be used along with immunotherapy. Immunotherapy, commonly referred to as “allergy shots” is a program designed to desensitize you to those substances to which you are allergic. A repeated injection of a sterile mixture (of those substances identified as causes of your allergies) allows your immune system to build up protection against them. After several months of weekly injections or daily sublingual drops of increasingly stronger doses you will reach a maintenance dose and continue to receive that dose at regular intervals. The size of doses and length of intervals between doses depends greatly on your response to the therapy. Some people will receive complete symptom relief by taking immunotherapy.
An ongoing program of avoidance, medication, immunotherapy, or a combination of these methods, under the direct supervision of your doctor, is the best approach to controlling your allergies and allowing you to live more comfortably in your existing surroundings.

Source: http://www.texassinuscenter.com/sites/default/files/allergy-testing-packet.pdf