PLEASE FILL OUT THIS
QUESTIONAIRE AND
BRING IT WITH YOU
FOR YOUR ALLERGY
TEST APPOINTMENT.
THANK YOU!
Ear, Nose & Throat Center of the Ozarks
Carolyn Nutter P.A.C
6823 Isaac’s Orchard Rd. Springdale, AR
479-756-8822 (Phone) 479-750-2082 (Fax)
Patient Instruction/Consent Form for Allergy Skin Testing
Skin Test: Skin test is a method of testing for allergic antibodies. A test consists of introducing small amounts
of the suspected allergen into the skin and noting the development of a positive reaction (which consists of a
welt, swelling or flare in the surrounding area of redness). The results are read at 15-20 minutes after the
application of the allergen.
The skin test methods are:
Prick Method: The skin is pricked with a needle where a drop of allergen has already been placed.
Intradermal Method: This method consists of injecting small amounts of an allergen into the superficial layers of the
skin.
Interpreting the clinical significance of skin tests requires skillful correlation of test results with patient’s
clinical history. Positive tests indicate the presence of allergic antibodies and are not necessarily correlated
with clinical symptoms. You will be tested to important (location) airborne allergens and possibly some foods.
These allergens include: Trees, grasses, weeds, molds, dust mites, and animal dander. The skin test generally
takes 45 minutes to 1 hour. Prick tests (also known as percutaneous) are usually performed on your back, but
may also be performed on your arms. Intradermal skin tests may be performed if the prick skin tests are
negative and are performed on your arms. If you have a specific allergic sensitivity to one of the allergens, a
red, raised, itchy bump (caused by histamine release into the skin) will appear on your skin within 15-20
minutes. These positive reactions will gradually disappear over a period of 30-60 minutes and typically no
treatment is necessary for this itchiness. Occasionally local swelling at a test site will begin 4 to 8 hours after
the skin tests are applied, particularly at sites of intradermal testing. These reactions are not serious and will
disappear over the next week or so.
DO NOT TAKE
1. Prescription or over the counter oral antihistamines should be stopped 4 to 5 days prior to scheduled skin
test. These included cold tablets, sinus tablets, hay fever medications, oral treatments for itchy skin, over
the counter allergy medications (such as Claritin, Zyrtec, Allergra, Actifed, Dimetapp, Benedryl, and many
others.) Prescription antihistamines such as Clarinex and Xyzol should also be stopped at least 5 days
prior to testing. If you have any questions whether or not you are using an antihistamine, please ask the
nurse or doctor. In some instances a longer period of time off these medications may be necessary.
2. You should discontinue your nasal and eye antihistamine medications, such as Patanase, Pataday,
Astepro, Optivar, or Astelin at least 2 days before the testing. In some instances a longer period of time
off these medications may be necessary. If you have any questions whether or not you are using an
antihistamine, please ask the nurse or doctor.
3. Medications such as over the counter sleeping medications (e.g. Tylenol PM) and other prescribed
drugs, such as amitriptyline hydrochloride (Elavil), hydroxyzine (Atarax), doxepin (Sinequan), and
imipramine (Tofranil) have antihistaminic activity and should be discontinued at least 2 weeks prior to skin
testing after consultation with your physician. Please make the doctor or nurse aware of the fact that you
are taking these medications so that you may be advised to how long prior to testing you should stop
taking them.
4. Zantac, Pepsid or other H2 blockers must be stopped 72 hours prior to testing.
5. Please let then physician and nurse know if you are pregnant or taking beta-blockers.
YOU MAY TAKE
1. You may continue to use your intranasal allergy sprays such as Flonase, Rhinocort, Nasonex, Nasacort,
Omnaris, Veramyst and Nasarel.
2. Asthma inhalers (inhaled steroids and bronchodilators), leukotriene antagonists, (e.g. Singular, Accolate)
and oral theophylline (Theo-dur, T-phyl, Uniphyl, Theo-24, etc.) do not interfere with skin testing and
should be used as prescribed.
3. Most drugs do not interfere with skin testing but make certain that your physician and nurse know about
every drug you are taking (BRING A LIST)..
Skin testing will be administered at this medical facility with a medical physician or 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 and shock (the latter under extreme circumstances.) 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 waiting room.
Please cancel with at least 48 hours notice. Due to length of time scheduled for skin testing, a last
minute change results in loss of valuable time that another patient might have utilized.
I have read the patient information sheet on allergy skin testing and understand it. 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.
Patient __________________________________________________________Date signed______________
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_______________
ALLERGY TEST QUESTIONAIRE
Date_____________
Patient________________________________________DOB________________Age_____
Please complete the following questions:
Have you ever had severe allergic reaction that required emergency care? YES / NO (if yes explain)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
What are the problems that brought you here? And how long have they bothered you?
1._______________________________________________________________________
________________________________________________________________________
2._______________________________________________________________________
_________________________________________________________________________
3.________________________________________________________________________
__________________________________________________________________________
4._________________________________________________________________________
___________________________________________________________________________
What other medical problems are you currently being treated for?
1.___________________________________________________________________________
2.___________________________________________________________________________
3.___________________________________________________________________________
4.___________________________________________________________________________
5.____________________________________________________________________________
Name________________________________________________ DOB_____________________
What medications are you currently taking? (Please list all in detail)
1.____________________________________ 2.______________________________________
3.____________________________________ 4.______________________________________
5.____________________________________ 6.______________________________________
7.____________________________________ 8.______________________________________
9.___________________________________ 10.______________________________________
Your current allergy problems started? (check all that apply)
____ Childhood
____ As an adult
____ Are similar to other family members
____ Keep you from living normal life
____ Are helped by medications
Are you bothered by?
____Grass
____Tree Pollen
____Ragweed
____Wind
____Dog
____Cat
____Horses
____Perfumes
____Pesticides
____ Cows
____ Barns
____Weather Changes
____Dusty places
____Moldy places
____Raking leaves
____New buildings
____Insect stings
____smoke
____medications
____Other_____________________________________________
Allergy History:
_____ I am currently on allergy treatment. What clinic? _______________________________
_____ I have had allergy treatment in the past. What clinic? ____________________________
How long ago? __________________________
____ I have a history of allergies in my family. (explain)
__________________________________________________________________________________________
__________________________________________________________________________________________
Name_____________________________________________ DOB_______________________
I have tested positive to (this applies if you have had a previous skin test):
____Pollens
____Molds
____Animals
____Foods
____Chemicals
____Medications
____House dust
____Dust mites
List all known allergies:
1.__________________________________________ 2. ____________________________________________
3.__________________________________________ 4.____________________________________________
5.__________________________________________ 6.____________________________________________
7. __________________________________________ 8.____________________________________________
9. __________________________________________ 10.___________________________________________
Symptoms that you have currently or in the past: (circle all that apply)
 Nasal symptoms (runny nose or congestion)
 Ear symptoms (pressure, pain)
 Mouth and/or Throat (post nasal drainage, sore throat, hoarseness, difficulty swallowing)
 Eye symptoms (itchy, increased drainage)
 Headaches
 Breathing problems (shortness of breath, cough, wheezing)
 Stomach symptoms (acid reflex, nausea, diarrhea)
 Skin problems (dry, eczema)
 Sleep problems (snoring, difficulty falling asleep)
Where do your symptoms bother you the most?
_____Home
_____Work
_____School
Are you regularly exposed to pets or other animals? YES / NO
Do you have pets in your home?
What kind of animals? ___________________________
Are you regularly exposed to smoke, perfumes, or other chemicals? YES / NO