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					                                                                                   Cypress Ridge Professional Center
                                                                                       2311 Cypress Cove, Suite 101
                                                                                           Wesley Chapel, FL 33544
                                                                                              Phone (813) 929-6673
                                                                                                Fax (813) 929-6633

                            SKIN ALLERGY TESTING
                                    Information and Appointment
Dear Patient,

Thank you for visiting. We look forward to skin-testing you to determine the substances to which you are allergic.
This test is a simple and easy one that we do on a regular basis to both children and adults. It is not painful and
almost everyone copes with it very easily.

The goal of the test is to identify what environmental substances cause you to have an allergic reaction. Once we
have that information, we can then plan a treatment course that will assist you in feeling more comfortable.

We have set aside 1-2 hours dedicated for your testing. If for any reason you are not able to keep this appointment,
please provide our office with enough advance notice so that we may offer this space to another patient.

You have been scheduled for allergy skin testing on ______________, in our Wesley Chapel office.

The testing will begin at _________ am / pm.

Please plan to be in our office for at least 1 ½ - 2 hours. On the testing day, please wear a short-sleeved shirt and
refrain from using skin creams. Testing is typically performed on the back, however additional testing may need to
be done on the arms.

Prior to skin testing you must be off all allergy medication, antihistamines, (Claritin, Clarinex, Allegra, Zyrtec,
Dimetapp, Astelin, Astepro, Patanase, Benadryl, etc.) for a minimum of seven (7) days. These types of drugs may
give a false negative result during the test. To help with your symptoms during that time, you may take a
decongestant (ex. Sudafed) assuming you have no medical contraindications to decongestant therapy (such as
hypertension, heart or lung problems, prostate problems, glaucoma, asthma). If you are unsure please check with
your primary care physician prior to starting decongestant therapy. You may continue to use nasal sprays such as
Rhinocort, Nasonex, Nasocort, or Flonase. However, use of Afrin or other over-the-counter nasal sprays are to be
avoided unless specifically advised by your doctor.

Patients taking Beta Blockers (via oral dose or eye drop), such as Tenormin, Inderal, or Lopressor (among many
others, see list) may NOT have skin testing done until they have been off these drugs for two weeks. If you have
any questions concerning your present medications, please ask us. We will be glad to let you know if any of the
medications you are taking are Beta Blockers. Switching from Beta Blockers to other medications MUST be done
under the supervision of your primary care physician.

You will be able to drive yourself home and go about the rest of your days planned activities.

Insurances requiring a referral will need to have the procedural codes of 95004, 95024 and”Allergy work-up” should
be checked off or written on the referral.

Should you have any further questions, please feel free to call our office. We look forward to helping you.

                                                                      Respectfully yours,
                                                                       Brett Scotch, D.O.
                                                                        Paul DiPasquale, D.O.
                                                                                      Cypress Ride Professional Center
                                                                                         2311 Cypress Cove, Suite 101
                                                                                                Wesley Chapel, FL 33544
                                                                                                    Phone (813)929-6673
                                                                                                       Fax (813)929-6633

                                  Allergy Patient Medical History Form

Patient Name: _________________________________              Age: _____ Sex: ____ DOB: ________ Occupation______________

A. Major Allergy Complaints: (list each and when started)


B. General Symptoms: (check all symptoms that apply)

     1. Pollen Allergy                    2. Dust Allergy                3. Mold Allergy             4. Contact Allergy
      Worse Outdoors                     Worse Indoors                 Worse indoors or work         Worse in specific rooms
                                                                   place                             Which room__________

      Worse on windy days                Better Indoors               Worse in low, damp places      Worse around animals
                                                                                                     Which: ____________

      Worse on clear days               Worse 30 minutes after        Worse mowing or playing        Worse in basement
                                     retiring                         in grass
      Worse in warm or cool air         Worse in cold weather         Worse on windy days            Worse near barn

      Worse in change of               Worse when sweeping                                           Worse with certain jewelry
      Better outdoors                   Worse when dusting
      Better indoors

5. Are symptoms constant or intermittent?: _____________________________________________________________________

6. During which months do you usually have symptoms?               7. During which months are symptoms most severe?

January                  June                November                 January            June            November
February                 July                December                 February          July             December
March                    August              All                      March             August           All
April                    September                                    April             September
May                      October                                      May               October

8. When did the symptoms begin?: ___________________________________________________________________



Patient Signature: _______________________________________   Date: __________________  Page 1 
                                                                                        Cypress Ride Professional Center
                                                                                           2311 Cypress Cove, Suite 101
                                                                                                  Wesley Chapel, FL 33544
                                                                                                      Phone (813)929-6673
                                                                                                        Fax (813)929-6633

C. Medical Information

1. Please list ALL medications you are currently taking, or have taken within the last 30 days:





2. Are you on any medications containing a Beta Blocker? Please check if you are currently taking or have taken in the last 30
days any high blood pressure, heart, eye, and/or any migraine medications as a beta blocker may be found in many of these
medications. (Please see the list of Beta Blocker medications to assure that you are not on any Beta Blocker medications.)

If yes, which one? _______________________________________________________________________________________

Reviewed By MA/Nurse

3. Have you ever been tested for allergy? If yes, when? __________________________________________________________

4. Have you ever been treated with allergy shots? If yes, when? ____________________________________________________


5. Have you ever been treated with under the tongue allergy drops? If yes, when? _____________________________________

6. Did you have any adverse reaction to testing, shots, or drops? ___________________________________________________

7. Have you ever had sinus surgery? If yes, when? _______________________________________________________________


8. Do you have any pets? If yes, what type? ____________________________________________________________________


9. Have you ever been hospitalized due to an allergic reaction or asthma? If yes, when? _________________________________


10. Do you have asthma? If yes, do you use a rescue inhaler more than once a week on average? __________________________

Physicians Initial

Patient Signature: _______________________________________   Date: __________________  Page 2 
                                                                      Cypress Ridge Professional Center
                                                                          2311 Cypress Cove, Suite 101
                                                                               Wesley Chapel, FL 33544
                                                                                      Phone (813) 929-6673
                                                                                        Fax (813) 929-6633

           **You MUST stop taking these medicines (7) seven days before the allergy test

Allegra/Allegra-D       (fexofenadine)
Antivert                (meclizine)
Atarax                  (hydroxyzine) – STOP 14 DAYS PRIOR
Benadryl                (diphenhydramine)
Claritin/ Claritin-D    (loratidine)
Phenergan               (promethazine)
Tylenol PM              (diphenhydramine)
Zyrtec/ Zyrtec D/ Xyzal

Antihistamine Eye Drops:                                 Nasal Antihistimines:
Pataday                                                  Astepro
Patanol                                                  Astelin               (azelastine)
Optivar              (azelastine)                        Patanase
Zaditor              (ketotifen)

Please let the Allergy nurse or Physician know if you are taking these medications.

Monoamine Oxidase Inhibitors (MAOIs)

LicoriceGreen Tea               Feverfew
Saw Palmetto                    Astragalus
St. Johns’ Wort

H-2 Blockers
Tagamet                         (cimetidine)
Zantac                          (ranitidine)
Axid                            (nizatidine)

**Singulair and nasal steroids (Flonase, Nasonex, Nasocort, Rhinocort) do not need to be

      Brett M. Scotch D.O.                                               Paul D. DiPasquale, D.O.
            Board Certified in Otolaryngology, Head & Neck Surgery, Facial Plastic Surgery
                                                                  Cypress Ridge Professional Center
                                                                     2311 Cypress Cove, Suite 101
                                                                           Wesley Chapel, FL 33544
                                                                              Phone (813) 929-6673
                                                                                 Fax (813) 929-6633

                                   Beta Blockers
Beta Blockers are used to treat high blood pressure, heart disease, headaches, and glaucoma.
These medicines make it much more difficult to reverse a systemic reaction to allergy testing or

Oral Medications
Generic                Brand
acebutolol             Sectral
atenolol               Tenormin, Tenoretic
betaxolol              Kerlone
bisoprolol             Zebeta, Ziac
carteolol              Cartrol, Cartrol Filmtab
carvedilol             Coreg
nadolol                Corgard, Corzide
esmolol                Brevibloc
labetolol              Normodyne, Trandate
metoprolol             Lopressor, Toprol
penbutolol             Levatol
pindolol               Visken
propranolol            Inderal, Inderide, Innopran
sotalol                Betapace
timolol                Blocadren, Timolide

Eye Drops
Generic                Brand
levobunolol            AK-Beta, Betagan
betaxolol              Betopic
metipranolol           Optipranolol
carteolol              Ocupress
timolol                Timoptic

**** Please notify our office if you are on any of the above-mentioned Beta-
Blockers , or if you have been prescribed any other Beta-Blocker classified
medications not listed above.***

Please check with your Physician if you are on a blood pressure medication, as it may
contain a Beta Blocker not listed above

Brett M. Scotch D.O.                                                       Paul D. DiPasquale, D.O.
           Board Certified in Otolaryngology, Head & Neck Surgery, Facial Plastic Surgery
                                                                         Cypress Ridge Professional Center
                                                                             2311 Cypress Cove, Suite 101
                                                                                 Wesley Chapel, FL 33544
                                                                                    Phone (813) 929-6673
                                                                                       Fax (813) 929-6633

                               Consent for Allergy Testing and Treatment

          The purpose of this form is to ensure that your decision to have this evaluation and
          treatment is made with the knowledge of the possible risks of this medical care.

          Generalized allergic reactions after skin testing are unusual, but there is always a
          possibility of a local or systemic allergic reaction.

          A local reaction (at the injection site) may appear as redness, itching, or localized

          A moderate reaction may appear as a rapid or weak pulse rate. In rare cases there
          may be some shortness of breath.

          These symptoms may require immediate treatment initiated in this office and
          possibly continued in a hospital setting.

          I certify that I have received and read the information sheet on BETA
          I certify that I am not on any BETA BLOCKERS (eye drops or oral medication). I
          understand that failure to disclose any medications or herbal medications that I am
          currently taking to my doctor could be life threatening during Allergy Testing and
          I authorize the physicians and medical staff of   ENT & Facial Plastic Surgery Specialists,
          PL to perform allergy testing and treatment.

          ________________________________                ______________________________
          Print Patient Name                              Patient Signature                       Date

          _________________________________________       _______________________________________
          Print Parent/Guardian (if Patient is a minor)    Signature / Relationship to minor Date

          _________________________________________       _______________________________________
          Print Witness                                    Witness Signature               Date

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