Practice Name Address State, City, Zip Phone: Fax: E-Mail

Practice name
Address
State, City, Zip
Phone: Fax:
E-mail:

Patient______

General Patch Testing

Date & Time Applied Date & Time Removed

Readings at 48 to 72 hours / Date / Initials / Date / Initials
# order
tested / Antigen / Induration / Erythema / Score / Induration / Erythema / Score
1 / Potassium Dichromate .5%
2 / Neomycin Sulfate 20%
3 / Thiuram Mix 1%
4 / Paraphenylenediamine free base 1%
5 / Cobalt Chloride, 6 H20 1%
6 / Benzocaine 5%
7 / Formaldehyde 1%
8 / Colophony 20%
9 / Lidocaine 15%
10 / Balsam of Peru 25%
11 / N-Isopropyl-N’-phenyl
Paraphenylenediamine .1%
12 / Wool Alcohols 30%
13 / Mercaptobenzothiazole 2%
14 / Epoxy Resin 1%
15 / Paraban Mix 16%
16 / Parateriarybutyl Phenol Formaldehyde Resin
1%
17 / Fragrance Mix 8%
18 / Quarterninum-15 1%
19 / Nickel Sulphate, 6H20 5%
20 / Methyl Methacrylate
21 / 5 Chloro-2-methyl-4- isothiazolin-3-one+2
methyl-4-isothiazolin-3-one .01%
22 / Sesquiterpene Lactone Mix .1%
23 / Thiomersal .1%
24 / Ethylenediamine dihydrochloride 1%
25 / Betametasone-17-Valerate
26 / N,N’ Diphenyl Paraphenylenediamine .25%
27p-Aminobenzoic Acid / p-Aminobenzoic Acid (PABA) 10%
28 / Propylene glycol 5%
29 / Carba Mix 3%
30 / Tetracaine Hydrochloride 1%

Grading

1= Weak non-vesicular Reaction: erythema, infiltration, and possibly papules (+)

2=Strong edematous and vesicular Reaction: erythema, edema, papules, and vesicles (++)

3=Extreme spreading, bullous, ulcerative Reaction (+++)

4=Doubtful Reactions, macular erythema only (?)

5=Irritant reaction (IR)

6=Negative Reaction (-)

Adverse reactions:______

Handouts given on where to avoid

Avoid these areas: ______

4/23/03 form developed