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Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco We look forward to seeing you on the day of your appointment. Please read the following beforehand to ensure that your visit is as productive as possible. Sincerely, APPOINTMENT DATE:
Before your first appointment with Dr. Davidson, 1. Please double check the location—we are only at 2100 Webster Street (Pacific Heights) on Friday mornings from 9:00 am to 12:30 pm. 2. If your insurance requires a referral, please bring it or have it sent to the office on the day of your visit; health plans will not approve your visit without the referral. 3. Set aside time—first visits, with testing, require roughly 90-120 minutes. 4. Please wear a shirt or sweater that can be easily removed for allergy testing. 5. If your hair reaches your shoulders, please wear it up on your head, or style it to be 6. If you are taking any medications (including “over the counter”), please check their
compatibility with allergy skin testing below:  Skin testing requires being off antihistamine pills to prevent false negative results. See Table 1. (reverse)
 “Beta-blocker” pil s and “beta-blocker” glaucoma eye drops make allergy skin testing dangerous. Before stopping these, check with your prescribing doctor. See Table 2. (reverse)
 Some antidepressants have antihistamine effects. A few (the MAO-inhibitors) make allergy skin testing dangerous. See Table 3. (reverse)
 Continue any nasal sprays (even for allergy, such as Flonase, Astelin, etc.), asthma inhalers, and topical creams. They are NOT a problem. 7. Kindly bring a list of your medications, inhalers, eye drops and creams to the office on 8. If you need to cancel or reschedule your appointment, remember to call us 24 hours in advance. We will charge your credit card a “No Show” fee of $100. NOTE: Please consult your prescribing doctor before stopping Beta-blocker
medications or MAO-inhibitor antidepressant medications. You must ensure it
is safe to stop them for several days. STOPPING THESE WITHOUT
SUPERVISION CAN RESULT IN SERIOUS ILLNESS OR EVEN DEATH.
See back of sheet for Tables 1, 2 and 3.
Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco Table 1. Antihistamines (usually found in allergy or cold medications and some sleep-aids).
Brand Names ®
Generic Name
Minimum Time Off
Table 2. Beta-blocker pills OR Beta-blocker (Glaucoma) eye drops: For high blood pressure, angina, arrhythmia,
migraines, tremor, stage fright and other conditions. These MUST be stopped as they may cause a dangerous
reaction. There are many other examples so please check with us or your prescribing doctor.
Brand Names ®—Partial List
Generic Name—
Minimum Time Off
Partial List
Table 3. Certain antidepressants and muscle relaxants can interfere with testing. Note: Most new “SSRIs” such as
Prozac, Zoloft, Paxil, Celexa and Effexor are NOT a problem. Wellbutrin is also NOT a problem.
Brand Names ®
Generic Name
Minimum Time Off
Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco NAME: ___________________ D.O.B _________ (PAGE 1)
Please bring this ALLERGY QUESTIONNAIRE to your visit with the doctor.
 Please make answers concise.
 Referred by:  Physician
What problem brings you to this appointment? Are your symptoms getting worse?  Yes  No Are symptoms better away from home?
When are your symptoms worse?  All year
Do you have any of the following symptoms?  Stuffy Nose Check any of the following which seem to trigger/cause symptoms or bother you:  Grass  Basements  Cosmetics  Aerosol sprays  Humidity  Exercise  House dust Previously had skin test or blood test for allergies?  Yes, years ago  No Results: Have you had allergy injections?  Yes  No When? On shots for Received steroid (cortisone, prednisone, etc.) drugs?  Yes  No When? Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco
NAME:___________________ D.O.B _______ (PAGE 2)
ENVIRONMENTAL SURVEY
How long have you lived in your residence?  Apartment/Duplex  Condominium/Townhouse Is your bedroom in the basement?  Yes  No Are there any smokers in your home?  Yes  No Heating system:  Forced air  Steam/radiator Do you use:  Wood stove  Fireplace  Dehumidifier  Air purifier  Air conditioning Pets:  None If exposed to pets, do have any of the following symptoms? Do you have allergy proof encasings for pillows/mattress/comforter?  Yes  No Pillows: Do you have water leaks or mold contamination (i.e. visible mold, smell of mold)?  Yes  No Is your dwelling excessively humid?  Yes  No What type of floor covering do you have in your bedroom?  Wall to wall carpet Occupation (current or former, if retired): FAMILY HISTORY
Not including yourself, does your immediate family experience any of these symptoms? Who?  Other allergies (drugs / insect sting / food) Certified by the Board of Allergy and Immunology Clinical Professor, University of California San Francisco
NAME:___________________ D.O.B _______ (PAGE 3)
PERSONAL MEDICAL HISTORY
Check all that apply:  Anemia / blood disorder Have you smoked in the past?  Yes  No When did you stop? Have you had your tonsils or adenoids removed?  Yes  No Have you had ear, nose, or sinus surgery? - List any food allergies you have experienced: - List any drug allergies you have experienced. (Describe any allergic reactions to painkillers like Advil, aspirin, Aleve, etc):  wheeze/asthma - Describe any reaction to insect stings you have experienced: - Describe any reaction to latex you have experienced: List all medications and dosages (including nasal sprays, prescription skin creams, inhalers, non-allergy medications and alternative or herbal products): Jeffrey M. Davidson
180 Montgomery Street #2370, San Francisco CA 94104 Tel 415-433-6673
Which is the best number to reach you? May we leave messages?
INSURED PERSON
Legal Name of Insured (Check if self ) EMERGENCY CONTACT
REFERRAL
Which M.D. referred you? (This is necessary for insurance) Which friend can we thank for your referral? Which other doctors do you see? I, THE UNDERSIGNED, HAVE INSURANCE COVERAGE WITH THE ABOVE-NAMED CARRIER. I request & consent to specialized medical care for allergies or related medical conditions, which may include prescription drugs, allergy testing & desensitization. I UNDERSTAND AND AGREE that I am responsible for all charges pertaining to my medical care regardless of my insurance status. I ASSIGN DIRECTLY TO Jeffrey M. Davidson M.D. all medical benefits otherwise payable to me for services rendered. I authorize the doctor to release any & all information necessary to secure the payment of benefits. I will pay co-payments and deductibles at the time of service & I will advise the office immediately of any changes to my insurance coverage. I understand that estimated financial patient responsibility is determined from information supplied by my insurer and that Dr. Davidson’s office cannot guarantee their accuracy. I will pay for any non-covered charges that result from my not informing the office of such changes. I will pay a $35 fee for bounced checks, attending physician letters, statements, or certificates and a $50 fee for appointments cancelled without 24-hour notice. Signed FOR OFFICE USE ONLY: HIPPA CONSENT FORM SIGNED

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