ENT and Allergy Specialists

Brian Broker, MD

Laurence Cramer, DO

Paul Swanson, MD

Carol Actor, MD

Geeta A. Bhargave, MD

Daniel P. Nadeau, MD

Bryn Mawr Office

825 Old Lancaster Rd.

Suite 300

Bryn Mawr, Pennsylvania 19010

610-415-1100

Phoenixville Office

826 Main St., Suite 201

Phoenixville, Pennsylvania 19460

610-415-1100

Pottstown Office

5 South Sunnybrook Rd.

Suite 300

Pottstown, Pennsylvania 19464

610-415-1100

East Norriton Office

342 West Germantown Pike

Suite 320

East Norriton, PA 19403

610-415-1100

POSSIBLE SAME DAY ALLERGY TESTING:

Must be off these for the following number of days:

ANTACIDS (H2 BLOCKERS) 5 DAYS

• Axid (nizatadine) • Tagamet (Cimetidine)

• Pepcid (famotidine) • Zantac (Ranitidine)

ANTIHISTAMINES, COLD MEDICINES AND SLEEP AIDS:

Over the counter allergy and cold medication such 2 DAYS as Dimetapp, Benadryl (diphenhydramine) Actifed, Tylenol PM and most over the counter sleep products as well as prescription sleep aids

Clarinex, Claritin (Loratadine), Alavert, Allegra, 7 DAYS Allegra-D, Xyzal, Zyrtec (Cetirizine), Antivert, Vistaril, Atarax (Hydroxyzine)

NOSE SPRAYS AND EYE DROPS:

Nasal Sprays: Patanase, Astelin(azelastine), 5 DAYS Astepro, Dymista

Eye Drops: Pataday, Pazeo and any over-the-counter Products

DO Continue to use your Intranasal Steroid sprays such as Flonase, Rhinocort, Nasonex, Nasacort and Nasarel, Veramyst. Asthma Inhalers (inhaled steroids and brochodilators) and leukotriene antagonists (eg Singular or Zyflo) do not interfere with skin testing and should be used as prescribed. Afrin (no more than 3 days) and Sudafed may be used.

*** Please note the above medications have generic forms and some medications may be an ingredient in certain medications; please be cautious when taking medications the week before your scheduled testing appointment.

***MUST BE COMPLETED AND RETURNED THE DAY OF TESTING OR MAY NOT BE ABLE TO COMPLETE THE FULL TEST***

QUESTIONNAIRE

GENERAL INFORMATION

Name: _______________________________________________________ Date:______________________________

Age:____________ Sex: _________ Referring Doctor: _______________________________________________

Parent:____________________________________Phone best reached ___________________________________

Address: ________________________________________________________________________________________

Occupation: _____________________________________________________________________________________

MEDICAL INFORMATION

What are the symptoms you are experiencing that brought you here today? ________________________________________________________________________________________________

Do your symptoms occur all year long or only during certain times of year? If so, which time(s) of year? ________________________________________________________________________________________________

What medications have you taken for these symptoms? ______________________________________________ ________________________________________________________________________________________________

Can you identify anything that makes your symptoms worse? _________________________________________

Can you identify anything that makes your symptoms better? _________________________________________

Have you ever been allergy tested before? q YES q NO Date:________________________ Location:_____________________________________

Do you have asthma? q YES q NO Do you have your inhaler? q YES q NO If yes, what medications are you taking? Have you been hospitalized for asthma?

________________________________________________________________________________________________

Do you think you are allergic to any foods? q YES q NO

Do you think you are allergic to any medications? q YES q NO

Do you think you are allergic to any insect stings? q YES q NO

Do you think you are allergic to any Latex? q YES q NO

List all the medications are you currently taking: ________________________________________________________________________________________________

Do you have a history of smoking? q YES q NO Quantity:_____________________________ Date quit:____________________________

List all surgeries and hospitalizations: _______________________________________________________________

Family History (circle): Asthma Allergies Eczema Emphysema Sinusitis Auto-Immune Disease

HOME ENVIRONMENT (please circle or complete):

Home type: Single Family Apartment Townhouse Other

Age of home:___________years

Flooring: Carpet Hardwood Tile Other

Indoor mold: q YES q NO

Central air: q YES q NO

Heating: Forced Air Radiator Other

Pets:_____________________________________________________________________ __________________

Smokers in home: q YES q NO

Occupation:____________________________________________________________ _____________________

FOR OFFICE USE ONLY:

Instructions were given on how to use: Epi-pen, Mylan generic, Auvi-Q HOLD FOR 3 SECONDS ONLY FOR EPI-PEN AND MYLAN GENERIC. Patient Initials: _______________ HOLD FOR 2 SECONDS FOR AUVI-Q. Patient Initials: _____________

Is this test 1&2? q YES q NO (If test # 2 only, review entire questionnaire sign and date):

Staff signature for test 1&2:____________________________________________________Date:______________

Staff signature for test 2 only:__________________________________________________Date:______________

Staff signature for food testing:_________________________________________________Date:______________

Have you had skin testing in the past calendar year? q YES q NO

If YES check benefits ________________________________________________________________________

Benefits allowed today q YES q NO Initials:_____________

Do you have food, gum, or candy in your mouth? q YES q NO If yes, please remove

Are you pregnant? q YES q NO

Please remove all watches and bracelets at this time.

Do you have any tattoos on your arms? q YES q NO (pricks can go on back, no IDs on back)

Is there any medical reason why we cannot test on your arms? ____________________________________

Any new medical conditions? q YES q NO _____________________________________________

Are you taking any new medication? q YES q NO _______________________________________

Do you feel you are in good health today? q YES q NO

CONSENT FOR ALLERGY SKIN TESTING:

Skin testing will be administered at this medical facility with a medical physician or other health care professional present since occasional reactions may require immediate therapy. These reactions may consist of any or all of the following symptoms: itchy eyes, nose or throat; nasal congestion; runny nose; tightness in the throat or chest; increased wheezing; lightheadedness; faintness; nausea and vomiting; hives; generalized itching; shock, and anaphylaxis, the latter under extreme circumstances. Please let the physician and nurse know if you are pregnant or taking beta-blockers. Allergy skin testing may be postponed until after the pregnancy in the unlikely event of a reaction to the allergy testing. Beta-blockers are medications that may make the treatment of the reaction to skin testing more difficult.

Please note that these reactions rarely occur, but in the event a reaction would occur, the staff is fully trained and emergency equipment is available.

After skin testing, you will consult with your physician or other health care professional who will make further recommendations regarding your treatment.

We request that you do not bring small children with you when you are scheduled for skin testing unless they are accompanied by another adult who can sit with them in the reception room.

I have read and understand the patient information sheet on allergy skin testing. The opportunity has been provided for me to ask questions regarding the potential side effects of allergy skin testing, and these questions have been answered to my satisfaction. I understand that every precaution consistent with the best medical practice will be carried out to protect me against such reactions.

Pt. Signature: _______________________________________________________________________________

Date _____________________________________

Print Name__________________________________________________________________________________

DOB _____________________________________

Parent or legal guardian* ______________________________________________________________________

Date signed _______________________________

*as parent or legal guardian, I understand that I must accompany my child throughout the entire procedure and visit.

Witness ____________________________________________________________________________________

Date signed _______________________________