Physician:______Clinic #:______
Patient:______DOB:______
□ RESPIRATORY
ALLERGY
PROFILE
TEST #: 3014
Dust Mite: D.farinae
Dust Mite: Dpteronyssinus
Cat Dander
Dog Dander
Cockroach
Mouse Epithelium
Mold: Alternaria alternata
Mold: Aspergillus
fumigatus
Mold: Cladosporium
herbarum
Mold: Mucor racemosus
Mold: P notatum
Tree: Ash
Tree: Cottonwood
Tree: Elm
Tree: Maple
Tree: Mountain Cedar
Tree: Mulberry
Tree: Oak
Tree: Pecan/Hickory
Tree: Sycamore
Tree: Walnut
Grass: Bermuda
Grass: Timothy
Weed: Pigweed
Weed: Ragweed
Weed: RoughMarshelder
Weed: Thistle, Russian
Food: Peanut
Food: Milk
Total IgE
Specimen Requirement:
7.0 mL whole blood or
3.0 mL serum in SST
CPT:
86003 X 29, 82785 X 1
Target:
· Persistent asthma on daily medications
· Chronic Rhinitis
· Nasal congestion
· Rhinorrhea
· Increased secretions
□ CHILDHOOD
ALLERGY
PROFILE
(Ages: 3 mo–2 yrs)
TEST #: _3013LLE E
Egg White
Milk
Peanut
Fish, Cod
Soybean
Wheat
Dust Mite: Dpteronyssinus
Dust Mite: D. farinae
Cat dander
Dog dander
Cockroach
Mold: Alternaria alternata
Specimen Requirement:
5.0 mL whole blood or
2.0 mL serum in SST
CPT: 86003 X 12, 82785 X 1
Target:
· Eczema
· GI distress
· Recurrent acute otitis media
□ FOOD ALLERGY
PROFILE
TEST #: 3012
Egg White
Milk
Peanut
Fish, Cod
Soybean
Wheat
Corn, maize
Walnut
Clam
Scallop
Shrimp
Total IgE
Specimen Requirement: 5.0 mL whole blood or
2.0 mL serum in SST
CPT: 86003 X 11, 82785 X 1
□ RECURRENT
GASTROINTESTINAL DISTRESS (ADVERSE FOOD REACTION) PROFILE
TEST #: 2010
Food Allergy - ImmunoCAP® Specific IgE Assays
· Cow’s Milk
· Codfish
· Corn
· Gluten
· Hazelnut
· Peanut
· Scallop
· Sesame Seed
· Shrimp
· Soybean
· Walnut
· Wheat
Celiac Disease –
EliA® Assays
· tTG IgA
· tTG IgG
· Gliadin IgA
· Gliadin IgG
Specimen Requirement:
7.0 mL whole blood or
3.0 mL serum in SST
CPT:
86003 X 12
83516 X 4
OTHER TESTS:
□ PERSISTENT UNEXPLAINED FATIGUE PROFILE
TEST #: 2011
Rheumatoid Arthritis Celiac Disease
· CCP IgG tTG IgA
Thyroid Disease tTG IgG
· TG IgG Gliadin IgA
· TPO IgG Gliadin IgG
Connective Tissue Disease
· ANA Screen (Symphony®)
· dsDNA
Celiac Disease
· tTG IgA
· tTG IgG
· Gliadin IgA
· Gliadin IgG
Specimen Requirement:
7.0 mL whole blood or
3.0 mL serum in SST
CPT:
Celiac 83516 X 4
CCP 86200
ANA 86038
dsDNA 86225
TG 86800
TPO 86376
All tests can be ordered individually
For further information, please call Medstar at 708.488.1000