ALLERGY TEST

ORDER FORM
Patients Name: _____________________________ DOB:____________INS:_____________

Panel I (requires testing for 212 environmental allergens)

Date ___/____/____

Panel II (requires testing for 260 environmental and food allergens) Date ___/____/____

Panel III (requires testing for 170 environmental allergens)

Date ___/____/____

Panel III (requires testing for 146 food allergens)

Date ___/____/____

DIAGNOSIS FOR ENVIRONMENTAL AND FOOD ALLERGENS

ENVIRONMENTAL
372.00 Acute Conjunctivitis

FOOD
995.3

Allergy unspecified

477.8

Allergic Rhinitis, cause unspecified

995.0

Anaphylaxis

477.8

Allergic Rhinitis due to other allergens

995.1

Angioedema

995.3

Allergy unspecified

693.1

Dermatitis due to food

995.1

Angioedema

693.1

Food Allergy, specified

995.0

Anaphylaxis

693.1

Food Allergy, unspecified

493.90

Asthma unspecified

691.8

Other Atopic dermatitis & related condition

493.20

Asthma w/o mention of status asthmaticus

708.9

Urticaria unspecified

491.21

Chronic Bronchitis with acute exacerbation

Other

(specify)

491.20

Chronic Bronchitis w/o mention of acute exacerbation

493.90

Chronic Obstructive Asthma w/o mention of asthmaticus

691.8

Other Atopic Dermatitis and related conditions

372.30

Other Chronic Allergic Conjunctivitis

461.9

Sinusitis unspecified

708.9

Urticaria unspecified

Other

(specify)

May require additional testing (intradermal), if not conclusive;

PATIENT SYMPTOMS:
Nose/Sinus, Ears
__ Chocking attack (Bronchial Asthma)
__ Congestion
__ Cough, SOB
__ Headache
__ Itching

Eyes
__ Dark Circles
__ Itching
__ Redness
__ Watery discharge
__ Other

Skin
__ Hives
__ Itching
__ Rash
__ Swelling
__ Other

Gastrointestinal
__ Abdominal pain
__ Constipation
__ Diarrhea
__ Gas
__ Other

__
__
__
__

Nasal drip
Sneezing
Watery discharge
Other

Ordering Physicians Signature: ________________________________________________________

NAME: ________________________________ DOB: _________________ DOS: _________________

Environmental & Food Allergens

1.
2.
3.
4.
5.
6.
7.
8.

A
Histamine
Ash Tree
Acacia
Birch Tree
Box Elder
Walnut Tree
Juniper Tree
Glycerin

1.
2.
3.
4.
5.
6.
7.
8.

E
Mycogone Mold
Candida Albicans Mold
Cephalosporium Mold
Epicoccum Mold
Fusarium Mold
Pullularia Mold
Hormodenrum Mold
Helminthosporium Mold

1.
2.
3.
4.
5.
6.
7.
8.

B
Maple Tree
#3 Oak Tree Mix
Mulberry Tree
Black Cottonwood
Cedar Tree
Chinese Elm
Privet Tree
Olive Tree

1.
2.
3.
4.
5.
6.
7.
8.

C
Wingscale Weed
English Plantain
Hemp Weed
False Ragweed
S/G/W Ragweed
Kochia Weed
Sheep Sorrel
Russian Thistle Weed

1.
2.
3.
4.
5.
6.
7.
8.

D
Common Mugwort Sage
Weed
Pigweed
Lambs Quarters Weed
#7 Grass Mix
Bermuda Grass
Aspergillus Mold
Penicillium Mold
Alternaria

1.
2.
3.
4.
5.
6.
7.
8.

I
Tomato Food
Beef Food
Kidney Bean Food
Pork Food
Whole Egg Food
Cows Milk Food
Brocolli Food
Cabbage Food

1.
2.
3.
4.
5.
6.
7.
8.

F
Curvularia
Dog Hair
Parakeet Feather
Horse Hair
Cat Hair
Rabbit Hair
Mite Mix
House Dust

1.
2.
3.
4.
5.
6.
7.
8.

J
Cumin Food
Eggplant Food
Dill Seed Food
Filbert Nut Food
Lentil Food
Strawberry Food
Lettuce Food
Millet Food

1.
2.
3.
4.
5.
6.
7.
8.

G
Cockroach
Cotton Linters
Tobacco Leaf
Mushroom food
Cacao Bean (Chocolate)
Asparagus Food
Garlic food
Halibut Food

1.
2.
3.
4.
5.
6.
7.
8.

K
Mint Food
Chicken Food
Whole Grain Oat Food
Mustard Seed Food
Paprika Food
Cherry Food
Cayenne Pepper Food
Brewers Yeast

1.
2.
3.
4.
5.
6.
7.
8.

H
Sugar Beet
Avacado Food
Corn Food
Orange Food
Black Pepper Food
Banana Food
White Potato Food
Soybean Food
Positive Reaction(s) [if any]

L
1. Almond Food
2. Onion Food
3. Rice Food
4. Whole Wheat Food
5. Sage Food
6. Coconut Food
7. Sugar Cane Food
Bakers Yeast Food

Allergen: Reaction:
4+ = SEVERE
3+ = MODERATE
2+ = MILD

*No mark indicates a negative result*

PATENT CONSENT FORM

I hereby request and consent to the performance of diagnostic testing on me (or on the patient, for whom I am legally responsible) by certified technician
employed by the diagnostic company perfuming the test.
I had opportunity to discuss the nature and purpose of this test and its implementation with my referring physician.
I, understand, and I am informed the performance of allergy testing on me (or on the patient, for whom I am legally responsible) cannot and will not be able to
diagnose any condition not directly related to my symptoms and which may develop later in life, including, but not limited to: heart disease, stroke, cancer,
diabetes, kidney disease, AIDS, hormone abnormality, mental illness, or substance abuse. I understand that laboratory test is not 100% accurate. In case the
scratch test is not conclusive, an additional intradermal test may be required.
I agree to report to the office manager any complaint or dissatisfaction that I may have with the services which I receive.
I agree that in case fees are not reimbursed by my insurance company for any reason, I will pay the office directory by cash or credit card. PATIENT
INITIALS___________
I understand there are medications, especially beta blockers when taken in conjunction with allergy testing, may accentuate an allergy reaction. PATIENT
INITIALS_________
These medications are, but not limited to:
BETA ADRENERGIC BLOCKING AGENTS
Anaframil Betagan
Betapace Tablets
Betimol
Betoptic
Blocarden
Brevibloc injection
Cantrol Filmtab Tablets
Coreg
Corgard
Inderal inujectable & LA
Inderide
Kerlone
Lopressor
Nadolol Tablets
Normodyne
Ocumeter
Ocupress
Sectral Capsulcs-Sorine
Tenoretic
Tenoromin
Timolide Tablets
Toprol-XL
Trandate
Timoptic, XE,Occudose(Timolol m.)
Visken
Zebets Tablets

CALCUM CHANNEL BLOCKERS

Adalat & CC
Adapin
Asendin
Cardizem-CD, SR, XT, XR, XT
Covers-HS
Diliscor
Isoptin
Lotreg
Nifodical XL
Nimotop
Norvasc
Plendil
Procardia
Sular Tablets
Tiazac Capsules
Vascor Tablets
Verelun & PM

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below I
agree to the above named procedures.
_____________________________________

__________________________________________

PRINT: Patient Name

PRINT: Name of Patients Guardian or Parent

_________________________________________
Patients Signature

________________________________________________
Patients Guardian or Parents Signature

_________________________________________
Date Signed

________________________________________________
Date Signed

ALLERGY HISTORY QUESTIONNAIRE

Name:
______________________________
___________________

DOB: _______________Todays Date:

PLEASE CHECK THE APPROPRIATE BLANKS AND ANSWER ALL QUESTIONS.

Do you have a family history of allergies? ___ yes ___ no
Describe your symptoms (most bothersome to least): ________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Are your symptoms? _____continuous _____ variable _____ year around _____or seasonal in nature
Have you had any allergic reactions to food? If yes, please list: _________________________________
What exposures or changes in your environment do you know or suspect make your symptoms worse or for that
matter better? _________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Do you have any allergies you know of or suspect to medications or other substances? If yes, please list:
___________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Are you taking any drugs, medications, eye drops, herbs, or vitamins? Please list any and all of these:
_______________________________________________________________________________________
_______________________________________________________________________________________
Have you taken allergy shots before? ____ yes ____ no

If yes, did they help? ____ yes _____ no

Have you ever had a whole body, life threatening, allergic reaction? ____ yes ____ no If yes, please describe this
reaction ____________________________________________________________________
_______________________________________________________________________________________
Do you smoke, have you smoked, or have smoke exposure? ____yes ____ no
Signature of the patient, if not a minor ______________________________________