Allergy test Packet

Please correct the errors described below.

Consent for Allergy Testing

I have been explained the following, and understand:

  1. I’m being tested for allergy cousins of my symptoms of nasal congestion, headache, sinus infections, ear infections, and other associated problems
  2. The reason for allergy testing is to determine my sensitivity to things that I inhale in my environment

Risks of this allergy test:

During allergy testing, you may experience an allergic reaction, a rash, asthma attack, a delayed reaction, gastrointestinal problems (diarrhea), headache, swollen arm, shock, or even life-threatening airway problems.

Alternatives to this allergy testing:

Blood testing, medical treatment, avoidance of offending substances.

Description of testing:

Skin testing is a method of detecting an allergic response on your body that may be causing your allergy symptoms. The test is done by introducing small amounts of these substances, called allergens, into your skin and watching for a positive reaction (a “wheal.”) These initial results are seen within 10 or 15 minutes after placing these antigens on your skin. Both skin prick and intradermal tests are done.

Interpreting the skin test helps you and us to better understand your allergy symptoms, and your history. A positive skin test indicates a response, but may not necessarily mean that it requires treatment. The skin is tested to important allergens from the Northwest region. This includes trees, grass, weeds, mold, dust mites, animal dander’s and other things based on your history. These tests will be placed on your arms, and you may get a positive reaction to these things over the first 10 or 20 minutes. These positive reactions generally fade, and disappear over a period of 30 to 60 minutes. We will often put something on to help with itchiness, but local swelling may start up to the next day or two. Usually these are not serious reactions and should disappear over subsequent days. If these delayed reactions occur, please measure them and report them to us by phone or at your next office visit.

I understand that the physician, office staff, and other assistance will rely on statements about the patient, the patient’s medical history, and other information in determining whether to perform allergy testing and treatment on the patient. It is imperative that I am truthful in my responses to questioning.

Additional procedures: I understand that there are no guarantees that testing will be positive, or that allergy treatment will be prescribed. It may be necessary to perform additional procedures, or emergency measures to help if a reaction such as itching, throat tightness, difficulty breathing, or other life-threatening reactions are realized. I will make sure to let the doctor or the medical staff know if these things arise.

Ability to manage an emergency:

I have been made aware that the office is fully equipped for the management of emergency should it arise. I authorize the practice to perform additional procedures as they seem necessary or appropriate, and to transfer my care to an emergency room if I have a significant reaction.


Prior to the placement of skin tests, I will let the medical assistant or doctor know:

  • If there are any new prescription medications, particularly blood pressure or migraine or glaucoma medicines
  • If the patient is pregnant
  • If the patient is currently having active asthma symptoms; experiencing wheezing, tightness in the chest, even if the patient hasn’t been diagnosed as having asthma
  • If the patient has a temperature more than 100°, or if the patient has pneumonia, bronchitis, or an acute illness
  • If there is an allergy flare-up, extreme sneezing, watery eyes, or other allergy symptoms
  • If the patients just finished cutting the lawn, working in the garden, or doing housework and were exposed to large amounts of pollen
  • If the patient is just finished or is about to exercise
  • If the patient has had an extremely stressful day
  • The patient has hives, shingles, or is currently recovering from a poison oak/ ivy outbreak


After the skin testing session, the results will be discussed and further recommendations will be made regarding allergy treatment. I will be given options for allergy treatment including immunotherapy or medication.

Declaration: I acknowledge that I have read this form, or had it fully explained to me. I understand these contents and have been given an opportunity to ask questions, and have received adequate answers to my questions. I understand that every precaution will be carried out to protect me from adverse reactions to testing and give my permission for the staff to proceed with allergy testing.

By signing below, I voluntarily requested consent to allergy testing as described above. I consent to treatment of any reactions that may arise.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

The following questionnaire is intended to help define your symptoms and provide valuable information and insights for your doctor. Answer the questions, rating to the best of your ability the problems you have experienced over the past two weeks.

Consider how severe the problem is when you experience it and how often it happens. please rate each item below on how “bad” it is by circling the number that corresponds with how you feel using this scale.

Please mark the most important items affecting your health (maximum of 5 items), in the right column.


DO NOT TAKE - Medications that interfere with skin testing.


ANTIHISTAMINES: Examples are Alavert (loratidine), Allegra (fexofenadine), Atarax (hydroxyzine), Benadryl (diphenhydramine), Xyzal (levocitirizine), Zyrtec (cetirizine), Astelin, Patanase.

ALL ALLERGY EYE DROPS: Examples are Pataday, Visine-A, Optivar, Livostin.

SLEEP AIDS OR MEDICATIONS W/ SLEEP AID: Examples are Unisom, Sominex, Tylenol PM, Midol PM, Ibuprofen PM. (Melatonin OK to continue)

ACID BLOCKERS: Examples are Zantac (ranitidine), Pepcid (famotidine), Tagament (cimetidine), Axid (nizatidine). (some acid blockers are fine, please ask if you are currently taking one not listed) *ASK DOCTOR BEFORE STOPPING THESE MEDICATIONS*


ANTI-NAUSEA MEDICATIONS: Examples are Dramamine, Reglan, Phenergan, Comopazine, Tigan, Antivet (meclizine), Scopolamine patch

COLD/FLU MEDICATIONS: Examples are Tylenol Cold & Flu, Nyquil, Dayquil, Actifed, Dimetapp.

TRICYCLIC/HETERO-CYCLIC ANTIDEPRESSANTS: Examples are Doxepin, Elavil, Anafranil, Norpramin, Sinequan, Tofranil, Pamelor, Vivactil, Desyrel *ASK DOCTOR BEFORE STOPPING THESE MEDICATIONS*

MUSCLE RELAXANTS: Examples are Parafon Forte, Flexeril, Norflex

CERTAIN SUPPLEMENTS: Examples are Vitamin C, Echinacea, Green Tea, St. John’s Wort

*Call the allergy department If you are not sure about a medication before you take it*


You WILL NOT BE TESTED if you are taking a Beta-Blocking Agent unless you consult your physician. DO NOT STOP BETA-BLOCKERS SUDDENLY OR ON YOUR OWN.

  • Acebutolol (Sectral)
  • Atenolol (Tenormin, Tenoretic) Betapace
  • Betaxolol (Kerlone, Betopic, Betagan eyedrops)
  • Bisoprolol (Zebeta, Ziac)
  • Timolol (Locadren, Timolide, & Timoptic eyedrops

  • Carteolol (Cartrol)
  • Carvedilol (Coreg)
  • Labetalol (Normodyne, Trandate)
  • Metoprolol (Lopressor, HCT Toprol-XL)
  • Metipranolol (Optipranolol)
  • Nadolol (Corgard, Corzide)
  • Nebivolol (Bystolic)
  • Penbutolol (Levatol)
  • Pindolol (Visken)
  • Propranolol (Inderal, LA, Inderide, LA)


Asthma Inhalers, Antibiotics, Contraceptives, Montelukast and Nasal Sprays (Examples are FLONASE)

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