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Allergy Evaluation Checklist

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					                                                                 Richmond Ear, Nose & Throat
                                                           8700 Stony Point Parkway, Suite 110
                                                                          Richmond, VA 23235

                                                                                 804-330-5501
                                                                        www.RichmondENT.com




Allergy Evaluation Checklist

Please complete ONE WEEK before your appointment.

Reasons for testing: Do you have at least ONE of the following? If not, stop and call us.

   •    Year-round allergy symptoms
   •    Seasonal allergies for more than three years
   •    Nasal polyps
   •    Asthma
   •    Eczema/Excessive Dry Skin
   •    Persistent Ear Infections

Reasons for caution: If YES to any question, please STOP and call us.

 yes    no      Are you less than 4 years old?
 yes    no      Might you be pregnant?
 yes    no      Do you feel sick today, compared to normal for you?
 yes    no      Have you recently been to the emergency room for asthma or allergy?
 yes    no      Are you using a rescue inhaler for asthma more than once daily?
 yes    no      Have you had a serious reaction to bee stings?
 yes    no      Have you ever had a life-threatening allergic reaction?
 yes    no      Does your skin turn red if lightly scratched?
 yes    no      Do you have a skin rash now?
 yes    no      Do you have heart disease or take a β-blocker medication? (See list next
page)
 yes    no      Do you take antidepressants or antacids? (See list next page)
 yes    no      Do you have glaucoma?


Before you return: Please follow EACH of these instructions.

   •    Stop antihistamines and anticholinergic drugs one week before test (See list
        next page)
   •    Continue asthma medicines and nasal steroids if needed
   •    Allow at least two hours for your visit
   •    Eat normally before you come to the office
   •    Do not plan strenuous activity for 24 hours after testing
   •    Wear short sleeves or sleeveless top
   •    Bring a book, music CD or videotape if you choose
   •    If you are sick or unable to keep this appointment, please call 24 hours in advance to
        avoid the $25 cancellation fee. Call if you have any questions.


     Certified by the American Board of                             Certified by the American Board of
  Facial Plastic and Reconstructive Surgery                                   Otolaryngology -
                                                                          Head and Neck Surgery
                                  Advanced Otolaryngology Allergy Evaluation

Patient Name: ________________________________ Date: _____/_____/____

                     MEDICATIONS THAT AFFECT ALLERGY TESTING

                    Stop all Antihistamines 7 Days before Skin Testing


Allergy preparations:

Azelastine (Astelin)
Brompheniramine
(Dimetapp, Lodrane)
Cetirizine (Zyrtec)
Chlorpheniramine
(Coricidin, Actifed, Contac,
Chlor-Trimaton)
Clemastine (Tavist)
Cyproheptadine
Desloratidine (Clarinex)
Diphenhydramine
(Benadryl, Sominex,
Genahist, Uni-hist)
Fexofenadine (Allegra)
Hydroxyzine (Atarax,
Vistaril)
Loratidine (Claritin, Alavert)
Promethazine (Phenergan)
All over-the-counter cough,
cold or allergy
combinations

Sleep aids:

Diphenhydramine
(Benadryl, Sominex,
Tylenol PM)

Acid controllers:

Cimetidine (Tagamet)
Famotidine (Pepcid)
Nizatidine (Axid)
Ranitidine (Zantac)




Revision 07/07/10     Reviewed by Physician or Nurse Practitioner: _______   Page 2 of 4
                                    Advanced Otolaryngology Allergy Evaluation

Patient Name: ________________________________ Date: _____/_____/____




         The following medications may make it UNSAFE to proceed with skin testing.
          Do not stop these drugs without the direction of the prescribing physician.
                     CALL US if you are taking ANY of these medications.

Beta Blockers:

Betapace (Sotalol)              Lopressor (Metoprolol)           Blocadren (Timolol)
Normodyne (Labetalol)           Brevibloc (Esmolol)              Sectral (Acebutolol)
Cartrol (Carteolol)             Tenormin (Atenolol)              Corgard (Nadolol)
Toprol XL (Metoprolol)          Coreg (Carvedilol)               Trandate (Labetalol)
Inderal (Propranolol)           Visken (Pindolol)                Kerlone (Betaxolol)
Levatol (Penbutolol)            Zebeta (Bisoprolol)

Glaucoma Medications:

Betagan (Levobunolol)           Ocupress (Carteolol)
Betoptic (Betaxolol)            Timoptic (Timolol)




Revision 07/07/10      Reviewed by Physician or Nurse Practitioner: _______         Page 3 of 4
                                 Advanced Otolaryngology Allergy Evaluation

Patient Name: ________________________________ Date: _____/_____/____




Revision 07/07/10   Reviewed by Physician or Nurse Practitioner: _______   Page 4 of 4

				
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