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Microsoft word - instructions for allergy testing.doc
Your allergy testing is scheduled for:______________ __________
We require 48 hour cancellation notice or you will be charged $50.00.
Please call 425.258.4361 if you need to cancel this appointment.
The Following Items Are Extremely Important: PLEASE READ
• Allergy skin testing takes approximately 1 (one) hour to complete.
• Please wear something short-sleeved or sleeveless.
• VERY IMPORTANT - DO NOT
take any antihistamines
for 48 hours prior
to your skin
testing appointment. These medications will affect your test results. Your appointment will be rescheduled if you have taken any of these medications within 48 hours of the testing.
A few common antihistamines are Allegra, Claritin, Zyrtec, Clarinex, or over the counter antihistamines such as Benadryl, Diphenhydramine (Sudafed), Tylenol PM, Advil PM, including many cold and cough medications. If you have questions about your medications consult your pharmacy.
• Be sure to eat something 1 hour before coming in for testing.
• Please do not wear any perfume, perfumed lotion or cologne to your testing appointment.
In general, please avoid perfumes and colognes when visiting our office, as allergy sensitive people can be affected by these scents.
• Please make the allergy staff aware of all medications that you are taking. Beta Blockers
are often prescribed for hypertension, cardiac problems, eye problems and for migraines. If you are taking a Beta Blocker, please bring this to their attention.
• Asthma patients: please bring your inhaler to your appointment, in case you feel the need
• If you are being re-tested, do not have your allergy shot within 5 days of your re-test.
If you do your shots at home, please bring with you the documentation sheets,
all of your vials (empty or expired) and a sample of the syringes that you are using to administer your shots.
• We ask that you do not
bring your children (including infants), or if a minor is being
tested, no siblings, as this is a distraction during testing. We do not have the facilities to care for children during testing.
• Pregnant patients or possibly pregnant patients cannot
• Insurance: Allergy testing is covered by most insurance plans. You should contact your
insurance to determine what your benefit is for allergy
Please complete IN FULL and bring with you the attached forms and the requested
items to your appointment.
Thank you for your cooperation
Patient name: ____________________________________ Date of birth: _________________ Do you have any of the following:
What is your worst season? (please circle)
Spring / Summer / Fall / Winter / Year round
How long have you lived in this area?_________ Where did you live before?_______________ Do you smoke? Yes No If you used to smoke, how long ago did you quit?______________ If you are a smoker, how many packs per day do you smoke? ___________________________ Is there anyone in your household who smokes?
Have you ever been tested for allergies before?
If you have been tested, what did you test positive for?_________________________________ If you were allergic did you ever have allergy shots or other treatment?____________________ Do you have a family history of allergies? Yes No Asthma? Yes No Eczema? Yes No Please check off the following if you have any of these symptoms:
___Ear Infections ___Sinus Infections ___Itchy Ears
___Acid Reflux ___Others____________________________________________________________
Please list all of the medicines that you are currently taking. If possible, list the name and dose of the medicine. Attach a list if necessary.
Allergy Testing Questionnaire – Page 2
Please answer the following questions to the best of your ability
Type Of Home?__________ Age of Dwelling?_____________ Age of the Carpet?___________
Do you have an Air Cleaner?________ Type of Heating?________ Type of Windows?________
Age of Mattress?__________ Age of Pillows?__________ Feather/Down Bedding?__________
What is your occupation?________________________________________________________
What type of pets do you have? Cat / dog / horse / cow / fish / other:______________________
Are your pets: indoor / outdoor / both ?
Do your pets sleep in your bedroom? Yes No
How often do your pets get bathed?________________________________________________
Have you ever been tested for food allergies? Yes No
Do you suspect that you might have food allergies?___________________________________
Do you avoid any foods for any reason?____________________________________________
Are you on a special diet?_______________________________________________________
Please use the following guide to determine how often you consume the following: (for example if you drink milk every day, place a “D” next to dairy)
(D) Daily (W) Weekly (M) Monthly (R) Rarely (N) Never
How much Water do you drink each day?_____________________________________
How much Caffeine do you have each day?____________________________________
How often do you consume Alcohol?_________________________________________
Is there anything else you would like us to know?_____________________________________
Prof. Nilkanth R. Pawar I.D.D. (Dairy Tech.), B.Tech (Dairy Tech.), M.Tech. (Dairy Chemistry) email@example.com Tel. : +91-2385-254754 Research and Teaching Activities: Prof. Nilkanth Pawar joined this Department in 2011 as an Assistant Professor and since involved in teaching various subjects of Dairy Chemistry to the B. Tech. (Dairy Technology) students. So far he is activel
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