Institute for Asthma and Allergy – Pediatric Skin Testing
11002 Veirs Mill Road, Suite 414 / / 5454 Wisconsin Avenue, Suite 700
Wheaton, MD20902-2538 / Chevy Chase, MD20815-6901
Tel (301) 962-5800 / Tel (301) 986-9262
Fax (301) 962-9585 / Fax (301) 907-7910
Michael A. Kaliner, MD / Martha V. White, MD / Athena Economides, MD / H. Henry Li, MD, PhD / Mark D. Scarupa, MD / David Jeong, MD

Patient name: Date of birth: _____/_____/______Testing Technician:

Last use of antihistamine: ______days Testing Date:: ____/____/______

  1. Percutaneous reported as: Allergen: Testing concentration: Location: back __arm___ Device: Duotip (ALK-Abello)
  2. Intradermal: 0.02 ml injected, Location: arm Testing concentration: All foods at 1:10 w/v; environmentals at 1:20 w/v unless otherwise indicated
  3. Results Longest diameter of wheal (W) and erythema (flare) (F) measured in millimeters at 15 minutes

Blank in results column indicates test was not performed, O=negative Extract manufacturer: Nelco and Concentration: 1:20, unless otherwise noted

A.Allergen: 1:10 (Concentration) / Prick / B.Allergen: 1:10 (Concentration) / Prick / C. Allergen: 1:10 (Concentration) / Prick / D. Allergen: 1:10 (Concentration) / Prick
W / F / W / F / W / F / W / F
Nuts / Fish / Fish cont / Shellfish
Almond / Bass / Swordfish / Clam
Brazil Nut / Bluefish / Trout / Oyster
Cashew / Carp / Tuna / Scallop
Hazelnut (Filbert) / Catfish / Crab
Peanut / Codfish / Lobster
Pecan / Flounder / Shrimp
Pistachio / Red Snapper
Walnut, English / Salmon / Saline
Sardine / Histamine
E. Allergen: (Concentration) / Prick / Intradermal / F. Allergen: (Concentration) / Prick / Intradermal / G. Allergen: 1:10
(Concentration) / Prick
W / F / W / F / W / F / W / F / W / F
Environmental / Environmental cont / Common Foods
Tree Mix 1 / Alternaria / Egg White
Tree Mix 2 / Cladosporium / Egg Yolk
Tree Mix 4 / Mold Mix 2 / Milk
Grass Mix 3 / Aspergillus Fumigatus / Peanut
Grass Mix 6 / Cockroach, American / Soy
Weed Mix 4 / Cockroach, German (1:100w/v) / Shellfish Mix
Weed Mix Special / Dog / Fresh Water Fish Mix
Weed Mix New / Cat (10,000BAU glycerinated) / Wheat
Ragweed / Dust Mite Mix (10,000AU glyc)
Tree Mix 1: American Elm, Red Maple, Mix Oak; Tree Mix 2: White Ash, Red Birch, Eastern Cottonwood, American Sycamore, Black Walnut; Tree Mix 4: Sweet gum, White Hickory, Mulberry, Red Cedar / Weed Mix 4: Cocklebur, Lamb's quarters , Rough Pigweed, English Plantain; Weed Mix Special: Yellow Dock, Rough Marsh Elder, Sheep Sorrel; Weed Mix New: Sage, Nettle, Mugwort
Grass Mix 3: (aqueous): Brome, Bermuda (10,000 BAU/ml), Johnson; Grass Mix 6: (100,000 BAU/ml, Glycerinated): Meadow Fescue, June, Orchard, Red top, Timothy, Perennial Rye / Mold Mix 2: Curvularia, Fusarium , Mucor , Aureobasidium, Rhizopus
Dust Mite, Mix: (10,000 AU/ml, Glycerinate): D. Farinae, D. Pteronyssinus
Shellfish Mix: Crab, Shrimp, Oyster, Lobster (1:10) / Fresh Water Fish Mix: Flounder, Cod, Halibut (1:10)

Comments: Prick: _____ Time: ______Reading time: ______; ID: _____ Time: ______Reading time: ______Revised 8-30-10