Allergy Questionnaire

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Allergy Questionnaire
IIBiIICQiUrQt.ry Ear, NQ;s"e,& Throat, P.A.
Otolaryngology
Charles F. Lano, Jr., M.D.
Stephanie Dawn Garza, R.N.-Allergy Nurse
Pam Clark, RMA-Allergy Tech
INSTRUCTIONS FOR ALLERGY TESTING
.:. PATIENTS ON BETA BLOCKERS CANNOT BE TESTED •
•:. STOP TAKING ALL ANTIBISTAMINES INCLUDING
ASTELIN NASAL SPRAY, SINGULAIR, AND ASPRIN, ONE
WEEK PRIOR TO TEST .
•:. WEAR BIG OR SLEEVELESS GARMENTS WHEN COMING
FOR THE TEST .
•:. IT WILL TAKE ABOUT TWO HOURS FOR THE TEST .
•:. THE RESULTS WILL BE GIVEN THE SAME DAY.
•:. IF BLOOD IS ·DRAWN IT WILL TAKE TWO OR THREE
WEEKS FOR THE RESULTS.
Hill Country Ear, Nose & Throat, P. A.
Allergy Center
Charles F. Lano, Jr., M.D. - Otolaryngologist
Stephanie Dawn Garza, R.N. - Allergy Nurse
Pam Clark, RMA - Allergy Tech
Allergy Treatment
What is Allergy? An allergy is an unusual reaction or increased sensitivity to certain
substances, called antigens, that are inhaled, ingested, injected or come in contact with
the skin.
What causes this reaction? People who are very sensitive to different antigens as
mentioned above develop antibodies (Immuno-globulin E or IGE). The allergic reaction
directly depends upon the concentration of these antibodies in the blood. The antigen
reacts with the antibodies on the surface of tissue cells in the body, releasing histamine
causing allergy symptoms like hives, itchy watery eyes, sneezing, coughing, nasal
drainage, nasal congestion, headaches and. gastrointestinal symptoms etc.
Non IGE Caused Allergy: Other things can cause an allergic response.
1.
2.
3.
4.
5.
6.
Asthma in adult life with no apparent cause
Cold, moist weather
Smoke
Chemicals
Psychological or physical distress
Occupational allergies: Most of these are non IGE
caused
Diagnosis: For successful treatment, the allergens responsible for the symptoms must
be identified. This is evaluated in the following manner.
1. A questionnaire is filled out by you the patient
2. Sinus x-rays may be done to rule out any sinus infection or other
problems such as nasal polyps or deviated nasal septum which may be
causing the symptoms
3. Blood may be drawn and tested for your IGE level here in the office
4. You will then be tested one of two ways:
SKIN TEST:
During the skin test a small amount of allergen (pollens, dust, molds, etc.) is injected
under the skin on the upper arm. There ill be 40 to 60 injections. It is not a painful
procedure. The tests take about 90 minutes to 2 hours. You must not take any
antihistamines for 3 full days before the test. Please check with our office concerning
you individual requirements. You may take non beta blocker blood pressure medication
or heart medication. Please make us aware if you are on a betablocker for blood pressure
or heart condition. We will not test if you are taking one. Tylenol can taken. Please try
to wear a short sleeve shirt so your upper arm will be easy to test on.
RASTTEST:
Blood is drawn and the serum is sent to a lab for evaluation of allergies. You do not have
to be off allergy medication before this test. It takes 10 days to 2 weeks to get the results
back. If you have not received your results from us within 2 weeks contact the allergy
department.
Treatment: Treatment involves weekly injections (immunotherapy) for the antigens
you are allergic to. This is done to increase your resistance to the allergens you are being
treated for. You will also be expected to do your part by avoiding anything you can
which affects you (dust, pets, mold, and mold foods, etc.) and by cleaning the
environment at home and at work. How long treatment should continue depends on the
patient's symptoms and response to treatment. Some patients may be able to discontinue
injections after 3-4 years; others may take them longer. There is no one method that
applies to all patients. If you prefer, after the maintenance dose has been determined,
which may take up to 12 weeks or longer, you may get your injections at your Medical
Doctor's office or you may continue to come to our office. You may also have the option
of administering your own injections at home but this must be decided by the Doctor.
You need to see Dr. Lano for consultation on the progress of your allergy treatment.
\ViE WILL BE GLAD TO ANSWER ANY QUESTIONS
HAVE CONCERNING THESE TESTS. WE ARERERE
YOU.
YOU MAY
TO HELP
42 Gruene Park Dr=New Braunfels, Tx 7813CF::Phone:830.629.583CF::Fax: 830.629.3647
Hill Country Ear, Nose & Throat, P.A.
Allergy Center
Charles F. Lano, Jr., M.D. - Otolaryngologist
Stephanie Dawn Garza R.N. - Allergy Nurse
Pam Clark, RMA - Allergy Tech
Beta Blockers
Anseiol (atenoloI)
Apo-Atenolol (atenolol)
Apo-Metoprolol (metoprolol tartrate)
Apo-Propranolol (propranolol hydrochloride)
Blocadren (timolol)
Betaloc Durules (metoprolol tartrate)
Betapace (sotalol hydrochloride)
Brevibloc (esmolol hydrochloride)
Bystolic (nebivolol HCI)
Cartrol (carteolol)
Coreg / Coreg CR (carvedilol)
Corgard (nadolol)
Corzide (nadolol-bendroflumethiazide)
Deralin (propranolol hydrochloride)
Dutoprol (metoprololhydrochlorothiazide)
Inderal / Inderal LA (propranolol hydrochloride)
Inderide (propranolol/HCTZ)
InnoPran XL (propranolol/hydrochloride)
Kerlone (betaxolol)
Levatol (penbutolol)
Lopresor! Lopresor SR! Lopressor I Lopressor HCT
Monocor (bisoprolol)
Normodyne (labetalol hydrochloride)
Normozide (labetalol )
Noten (atenolol)
Novo-Metoprolol (metoprolol succinate)
Novopranol (propranolol hydrochloride)
Nu-Metoprolol (metoprolol succinate)
Nu-Metop (metoprolol tartrate)
Presolol (labetalol hydrochloride)
PropranololIpropranolol hydrochloride)
Rhotral (acebutolol)
Sectral (acebutolol)
Sotacor (sotalol hydrochloride)
Tenormin (atenolol)
Tenoretic (atenolol! chlorthalidone)
Tensig (atenolol)
Timolide (timolol! HCTZ)
Timoptic, XE (timolol)
Toprol, XL (metoprolol succinate)
Trandate (labetolol hydrochloride)
Transicor (oxprenolol)
Visken (pindolol)
Zebeta (bisoprolol)
Ziac (bisoprololl HCTZ)
(metoprolol, metoprolol HCTZ)
Name
~
Male
Female __
Occupation
Pro~nent~aterlalsusedat~ork
Do you use a hurnldlfier?
Age ----'-------
Date -----
-------------------------
---------------------------~
Yes-No
--
Inside Home
Smoking Habits
Animals
___
Plants
___
Cigarettes
--Dog
__
Rugpads
___
Cigars
---Cat
---Rugs
-
Pipes
-
- __ - Carpeting
___
Stopped smoking 19 --
---Rodent
-_
Insect
sprays
__
- Years smoked
___
----
ill
the home
Birds
Other
Does anyone else in your home smoke?
Pillow
Mattress
---None
---
Cotton
Trees
What is near your home?
---
Foam Rubber
_-_
Foam Rubber
Weeds
----
Feather
---
Feather
Barn
---
Dacron
Don't know
---
Water bed
___
Don't know
Fields
Factory
_-_
---_Water·
---Other
System
Heating
Air Conditioning
Are your symptoms?
--Oil
___
Bedroom
---
--Gas
---
Window Unit
---Erratic
---Coal
---
Central Unit
---
-
__
Electric
--Wood
- __ Other
Do your symptons interfere with your life?
None
--
Are your symptoms?
Not at all
------'-
Slight
A little
_-_
Moderate
Moderately
---
Severe
Prevents normal activity
Yes
Fall.
- __
Winter
- __
Year around
__
No
If soexpillin.
Have you ever been allergy tested before?
Yes
If yes, when and did you take allergy injections?
Dldit seem to help your symptoms1
Present rarely
Do your symptoms interfere with your sleep?
--Spring
___
Present most
of the time
---AtWork
___
When are your symptoms worse?
Constant
~
No'
_
_
_
~----
__
Is there a family history of:
-_
__
__
__
Nasal allergy
Runny nose
Hay fever
Nose bleeds
__
--_
__
--
Frequent colds
__
Bronchitis
__
__
__
__
-__
__
-__
__
Hearing loss
Ear infections
Ear buzzing, ringing
Dizziness
Eye infections
Swollen eyelids
Eczema
Rash
Headaches
Lethargic behavior
__
__
__
---__
--.
~-
Frequent laryngitis
Hoarseness
Frequent sore throats
Frequent Diarrhea
Stomach Cramps
Hives
Itching
Chronic fatigue
Insomnia
Some of the following may cause your symptoms
-__
__
-__
__
__
Indoors
Outdoors
Weather changes
Wet weather
Dry weather
Windy day
Hot day
List any food or item ( soap, perfumes,
runny nose
itchy nose
sneezing
dryness.
blockage
bleeding
nasal polyps
crusting
post nasal drainage
watery drainage
broken nose
septal deviation
__
__
__
__
__
__
__
or make them worse, check those that do.
Cold days
Air conditioning
Damp areas
Hay
Lawn mowing
Dusty environment
High pollution days
shampoos,
-'------
__
Animals
Smoke
Alcoholic beverages
Cheese
Milk
etc.) you are aware you are allergic to ...
itchy eyes
watery eyes
eye infections
swollen lids
redness
Ears
hearing loss
itching
fullness
pain
buzzing
dizziness
drainage
Chest
cough
pneumonia
wheezing
asthma
bronchitis
Mouth breathing
Chronic cough
Asthma
'Pneumonia
Mouth
- __
__
~_
--
Skin
itching
burning
dryness
mouth breathing'
Other Symptoms
hives
eczema
itching
rash
swelling
Any known allergic reaction for ....
--Bees
--Wasps
~-
Mosquitos
--
Insects
Do you have any medical problems?
--
High Blood Pressure
__
Heart Disease
--
Diabetes
-__
Thyroid problems
List any others
Who is your medical doctor?
Do you take aspirin regularly?
Yes --
No-_
STOP ALL PRESCRIPTION ANTIHISTAMINES ONE WEEK BEFORE THE SKIN TEST.
OVER THE COUNTER i\NTIHISTAMINES
NEED TO BE STOPPED 3 DAYS BEFORE THE SK1N TEST
BXCEPT BENADRYL. BENADRYL MUST BE STOPPED 24 HOURS BEFORE THE SKIN TEST.
Beta Blockers are used to treat high blood pressure and to prevent headaches. If you are on a beta blocker
olease notify the office. We CANNOT treat or test for allergies if you are taking this class of medicine.
.Iave you ever had to go to the emergency room because of an allergic reaction?
f yes, please explain:
lave you ever had a reaction to foods, chemicals, detergents, plants, etc.? .
f yes, please explain:
F YOU HAVE EVER HAD AN ALLERGIC
REACTION
TO ANYTHING
PLEASE
LET US KNOW.
'

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