PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit.

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PREPARATION FOR ALLERGY TESTING *** Please read this information at least one week before your upcoming visit. In order to obtain valid and useful skin testing results, you will need to stop the use of certain medications for a specific amount of time before your appointment. All over-the-counter (OTC) and prescription antihistamines: Benadryl (diphenhydramine), Allegra (fexofenadine), Zyrtec (cetirizine), Claritin (loratadine), Alavert (loratadine), Xyzal (levocetirizine), Clarinex (desloratadine), and Atarax (hydroxyzine) need to be stopped 5 days before your appointment. Antihistamine nose sprays: Astelin (azelastine), Astepro (azelastine), Patanase (olopatadine), and Dymista (Fluticasone/Azelastine) need to be stopped 5 days before your appointment. Allergy eye drops: Pataday/Patanol/Pazeo (olopatadine) and OTC Allergy eye drops (Zaditor, Alaway, OphconA, etc.) need to be stopped 5 days before your appointment. Please keep in mind that many OTC cough and cold medications contain antihistamines including Tylenol PM, Tylenol Cold and Cough, and Tylenol Flu. These should also be stopped 5 days before your appointment. Nasal steroid sprays including Flonase/Flonase Sensimist/Clarispray (fluticasone), Nasacort (triamcinolone), Rhinocort (budesonide), Nasonex (mometasone), Qnasl (Beclamethasone), and Zetonna/Omnaris (Ciclesonide) do not need to be stopped before your appointment. Singulair (Montelukast) does not need to be stopped before your appointment with us. Inhalers for asthma, cough, or wheezing do not interfere with skin testing and should not be stopped before your appointment. There are not restrictions on diet; no fasting is needed for allergy testing. You can expect your first visit to last from 1-2 hours. For pediatric patients, please ensure that the family member who is bringing the patient can provide an accurate and detailed history. Patients under the age of 18 years must be accompanied by a parent or guardian. Please fill out the attached Allergy/Immunology New Patient information form and bring it with you as this will save you time during your appointment. Please bring any currently prescribed allergy, asthma, or eczema medications with you. If you are unable to stop any of the above medications as requested or a have any other questions please call us in advance at 704-355-9659 or 704-667-3960. CLT-990 (11/17)

ALLERGY and IMMUNOLOGY NEW PATIENT FORM Patient Name: Emergency Contact Information: Name Emergency contact number Relationship Age Physicians (Please list name and address of each practitioner): Referring Physician Primary Physician if different from above Medical History: Main reason for the allergy or immunology evaluation? How long has the problem been occurring? How severe are the symptoms when you or your child s allergies are active? No problem Minimal problem Mild Moderate Severe Very severe Fatigue 0 1 2 3 4 5 Trouble sleeping 0 1 2 3 4 5 Irritability 0 1 2 3 4 5 Dizziness 0 1 2 3 4 5 Sore throat 0 1 2 3 4 5 Sinus headache/pressure 0 1 2 3 4 5 Sneezing 0 1 2 3 4 5 Nasal itching 0 1 2 3 4 5 Nasal blockage 0 1 2 3 4 5 Nasal green/yellow mucus 0 1 2 3 4 5 Clear watery mucus 0 1 2 3 4 5 Drip down the throat 0 1 2 3 4 5 Loss of sense of smell 0 1 2 3 4 5 Snoring 0 1 2 3 4 5 Earache 0 1 2 3 4 5 Eye itching 0 1 2 3 4 5 Eye redness 0 1 2 3 4 5 Eye watering 0 1 2 3 4 5 Eye burning 0 1 2 3 4 5 Shortness of breath 0 1 2 3 4 5 Coughing 0 1 2 3 4 5 Wheezing 0 1 2 3 4 5 Chest tightness 0 1 2 3 4 5 Chest pain 0 1 2 3 4 5 Phlegm 0 1 2 3 4 5

When do allergy symptoms occur? Seasonal (Fall Winter Spring Summer) Year round What makes symptoms worse? Animals Dogs Cats Dust Home Indoors Workplace Outdoors Trees Cut grass Weeds Mold Rain Wind Weather Change Changes in Barometric Pressure Emotions Exercise Infection Irritants Chemicals Perfumes Smoke In the past 12 months, how many times did you or your child miss work or school due to allergies, asthma or sinusitis? go to the emergency room due to allergy, asthma or sinusitis? get admitted to a hospital for allergies, asthma or sinusitis? use antibiotics for sinus, chest or ear infections? require oral steroids asthma or sinus treatment? Previous allergy testing: 9 No 9 Yes, year by Dr. located Previous allergy shots: 9 No 9 Yes, from Do you have Asthma? 9 No 9 Not certain 9 Yes If Yes, last lung function test was performed in year of to Reactions to foods if any, please list Reaction to insect bites, if any please describe Latex exposure regularly? 9 No 9 Yes If yes, what and where? Any symptoms with latex exposure? 9 No 9 Yes Rash, Itching, Hives, Sneeze, Itchy nose, Runny nose, Congestion, Eye symptoms, Cough, Wheeze, Chest tightness, Shortness of breath, Other: Please list all medications that have been tried specifically for allergies (including prescription or overthe-counter pills, nasal sprays, inhalers, and eye drops): Previous or Current Medical Illnesses and Surgeries: Is there a history of sinus surgery? 9 No 9 Yes If yes, date and reason:

Social History (Adults Only): Occupation: Are you concerned about any occupational allergy exposure? 9 No 9 Yes If yes, please describe: Present marital status: 9 Single 9 Partnered 9 Married 9 Divorced 9 Widowed Do you use tobacco in any way? 9 No 9 Yes If yes, frequency? Have you smoked in the past? 9 No 9 Yes If yes, when did you stop? Social History (Children Only): Is your child in a daycare or preschool? 9 No 9 Yes Is your child exposed to tobacco smoke? 9 No 9 Yes Who lives at home with your child? Environmental History: Pets? 9 No 9Yes, please list Floor coverings in your home: 9 carpet 9 wood 9 tile 9 other hard surface Mold or known water damage in home? 9 No 9 Yes Free standing humidifier in your home? 9 No 9 Yes How often are the air filters on the return vents changed? Family History: Nasal allergies: 9 No 9 Yes, if so, relation to patient Asthma: 9 No 9 Yes, if so, relation to patient Eczema: 9 No 9 Yes, if so, relation to patient Food allergies: 9 No 9 Yes, if so, relation to patient Recurrent infections: 9 No 9 Yes, if so, relation to patient Medications: Please list all medications you are currently taking (prescribed, OTC and supplements): Name Dose daily or as needed Any medication allergic reactions? 9 No 9 Yes Please describe:

Review of Systems (Please check any symptoms that are ongoing): Constitutional 9 recurrent fevers 9 unexplained weight loss 9 unexplained weight gain 9 weakness/fatigue 9 night sweats Head 9 headaches 9 dizziness 9 sinusitis Eyes 9 redness 9 itching 9 irritation 9 dry eyes 9 eyelid swelling Ears/Nose/Throat/Mouth 9 decreased hearing 9 sneezing 9 nasal drainage 9 nasal congestion 9 itching 9 sinusitis 9 nosebleeds 9 sore throat 9 snoring 9 mouth sores Respiratory 9 shortness of breath 9 chest tightness 9 chronic cough 9 wheezing 9 shortness of breath with exertion only 9 coughing up blood Cardiovascular 9 chest pain 9 high blood pressure 9 irregular heartbeats 9 palpitations Gastrointestinal 9 heartburn / GERD 9 lactose intolerance 9 diarrhea 9 vomiting 9 abdominal pain Endocrine 9 diabetes 9 heat / cold intolerance Blood/Lymphatic 9 swollen lymph nodes 9 easy bruising/bleeding Musculoskeletal 9 joint pain 9 muscle aches 9 weakness Skin 9 Rashes 9 Hives or swelling 9 Dry skin Psychiatric 9 depression 9 anxiety 9 mood swings 9 Yes, Antihistamine medications have been withheld for the past days. 9 No, Antihistamine medications have not been withheld for the past seven days.

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