Allergy Questionnaire Posted on January 10, 2025 by Coastal Carolina Otolaryngology Step 1 of 2 50% Coastal Carolina Otolaryngology Allergy QuestionnairePatient Name (First)Patient Name (Last)Email Date of Birth MM slash DD slash YYYY Date MM slash DD slash YYYY Have you been allergy tested before? Yes No If yes: When?If yes: Where?2. Please choose all of the symptoms that you experience: Wheezing Sneezing Congestion Postnasal drainage Loss of voice Hearing loss Shortness of breath Loss of smell Bad breath Headaches Snoring Fatigue Runny nose Eczema Frequent clearing of throat 3. Are your symptoms seasonal or year-round?Do your symptoms flare up often? Yes No How long do your flare-ups last?Are your symptoms worse during a certain time of day?Are your symptoms worse during certain seasons?Do you have upper respiratory infections more than three times a year? Yes No Do you have pets? Yes No If so, what kind?How long have you lived in the area?How long have you lived at your current address?Did you have allergy or asthma symptoms in your previous residence or state? Yes No Do you have a family history of asthma? Yes No Were you diagnosed with asthma as a child? Yes No Please choose all the medications below that you have taken in the last year: Inhalers Antihistamines Eye drops Decongestants Cough syrups/drops Nose sprays Beta-blockers Blood thinners Antidepressants Sleep medications Antacids Have you had or do any of the following apply to you? Asthma Anaphylaxis Beta-blockers Food allergy Angioedema Pregnancy Hives Dermatographism Allergy Testing Patient Instructions Your appointment is on:Your doctor or provider has recommended that you be tested for allergies to determine if various pollens or other airborne allergens may be contributing to your current symptoms. You must stop certain medications prior to allergy skin testing. Please DO NOT take any medications that contain antihistamines for 5-7 days prior to the testing. These include, but are not limited to the following: Common antihistamines (this is not a complete list) BENADRYL® (diphenhydramine), Claritin® (loratadine), Allegra® (fexofenadine), ZYRTEC® (cetirizine), Xyzal® (levocetirizine), Clarinex (desloratadine) Over-the-counter cold and cough remedies Dimetapp®, Robitussin, TYLENOL® Cold & Sinus, Chlor-Trimeton Prescription or over-the-counter sleep aids Ambien, Lunesta, Midol PM, TYLENOL® PM, Excedrin® PM, Dramamine® Nasal spray antihistamines Patanase, Astepro®, Astelin Eye drop antihistamines Optivar, Pataday® Herbal supplements, multivitamins and vitamin C Must be stopped seven days prior to testing Please wear a SHORT-SLEEVE SHIRTstrong, as the allergy testing will take place on the upper and lower arms. The testing will take between 60 to 90 minutes to complete. PLEASE MAKE SURE YOU ARE 15 MINUTES EARLY. If you are on a beta-blocker, we cannot perform testing unless a prescribing M.D. gives you another form of medication Examples of beta-blockers are: Bystolic (nebivolol) Coreg (carvedilol) Corgard (nadolol) Inderal (propranolol) Levatol Lopressor (metoprolol) Tenormin (atenolol) Zebeta (bisoprolol) Timolol (eye drops for glaucoma) Please note: if you have not received a call from the allergy department within five business days, please call (843) 449-6449 option 7.
