Patient instruction and consent sheet for allergy skin testing

West Houston Allergy & Asthma, P.A.
705 S. Fry Rd. #115 Katy, TX 77450 281.647.9204
12121 Richomond Ave. #217, Houston, TX 77082 832.243.1850
Pardeep S. Rihal, M.D.
Patient Instruction and Consent Sheet for Allergy Skin Testing

Skin Test: Skin tests are a method of testing for allergic antibodies. A test consists of introducing small amounts of the
suspected substance, or allergen, into the skin and noting the development of a positive reaction (which consists of
local swelling with a surrounding area of redness). The results are read 15 to 20 minutes after application of allergen.
The skin test methods that are available for use are:
Prick Method: The skin is pricked with a prong which has allergen on its surface.
Intradermal Method: Injection of small amounts of allergen into the superficial layers of the skin.
Multi-Test Method: Multi-prong devices, covered by allergen, are held against the skin for 5-10 seconds.
Interpreting the clinical significance of skin tests requires a skillful correlation of the test results with the patient’s clinical history. Positive tests indicate the presence of allergic antibodies and are not necessarily correlated with clinica l symptoms. You will be skin tested for important airborne allergens in the greater Houston area and possibly some foods. These allergens include grasses, weeds, trees, molds, dust mites, pet dander, and selected foods. The consultation generally takes 45 minutes to one hour. Prick tests will be performed on the arms or back. If needed, intradermal tests will be performed. Local reactions from skin testing usually resolve gradually over 4-6 hours. Sometimes the local reactions can last a few days. Contact us if you have questions. If testing for antibiotics, caines, venoms, or other biological agents is required, the same guidelines apply. __________________________ agent(s) may also be tested if requested by your physician. We advise you not to use prescription or over-the-counter anti-histamines for 2-3 days prior to the scheduled skin testing. These may interfere with the results of the tests. Medications to be avoided include Claritin, Clarinex, Allegra, Zyrtec, Actified, Drixoral, Dimetapp, Dristan, Ornade, Benadryl, C-phen Trinalin, Xyzal, Patanase, and Astelin/Astepro. Sometimes other medications may interfere with test results including antidepressants, medications used to treated ulcers and sleeping medications. Continue other medications prescribed for any other medical conditions you have. Continue asthma medications and nasal sprays other than Astelin, Patanase, or Astepro.
Please inform the physician of the following:
If you are on any heart medications such as beta blockers or any antidepressants. Please list all of your medications. If you are pregnant, have a fever, have wheezing; signs or symptoms of any infection. Skin tests will be administered at this medical clinic with a physician or his/her delegate on the premises as occasional reactions may occur which would require immediate therapy. These reactions may consist of any or all of the following symptoms: itchy eyes, itchy nose, itchy throat; nasal congestion, runny nose, tightness in the throat or chest, wheezing, lightheadedness, faintness, nausea and vomiting, hives, generalized itching, and shock. The latter occurring under extreme circumstances. Please note that these reactions rarely occur but in the event a reaction would occur, trained staff is available with appropriate treatment options as well as access to a nearby emergency room. I have read the patient information sheet on allergy skin testing and understand it. The opportunity has been provided for me to ask questions regarding the potential side effects of allergy skin testing and these questions have been answered to my satisfaction. I understand that every precaution consistent with the best medical practice will be carried out to protect me against such reactions. Patient:_____________________________________________ Date:_________________ Parent/Guardian______________________________________ Date: _________________ Witness:____________________________________________ Date:_________________

Source: http://www.westhoustonallergy.com/pdf/skin%20testing%20consent.pdf