Professional Documents
Culture Documents
ORDER FORM
Patients Name: _____________________________ DOB:____________INS:_____________
Date ___/____/____
Panel II (requires testing for 260 environmental and food allergens) Date ___/____/____
Date ___/____/____
Date ___/____/____
FOOD
995.3
Allergy unspecified
477.8
995.0
Anaphylaxis
477.8
995.1
Angioedema
995.3
Allergy unspecified
693.1
995.1
Angioedema
693.1
995.0
Anaphylaxis
693.1
493.90
Asthma unspecified
691.8
493.20
708.9
Urticaria unspecified
491.21
Other
(specify)
491.20
493.90
691.8
372.30
461.9
Sinusitis unspecified
708.9
Urticaria unspecified
Other
(specify)
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
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
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.
_____________________________________
__________________________________________
_________________________________________
Patients Signature
________________________________________________
Patients Guardian or Parents Signature
_________________________________________
Date Signed
________________________________________________
Date Signed
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 ______________________________________