ALLERGEN TEST REQUEST FORM Department of Laboratories St. Louis, Missouri 63110

Transcription

1 Date} NAME ADDRESS ACCOUNT INFORMATION PHONE ORDERING PHYSICIAN BILL TO: 9 ACCOUNT 9 PATIENT/INSURANCE 9 ALTERNATE SEND ADDITIONAL COPY OF REPORT TO: CLIENT NUMBER/PHYSICIAN NAME PHONE/FAX NUM. PHYSICIAN S ADDRESS CITY, STATE, ZIP COLLECTION TIME FASTING COLLECTION DATE URINE hrs/vol : AM PM YES 9 NO 9 hrs vol STAT CALL RESULTS TO: COMPLETE AND (# ) ATTACH STAT FLYER BJH REGISTRATION # ALLERGEN TEST REQUEST FORM Department of Laboratories St. Louis, Missouri PATIENT RESP. PARTY INSURANCE PHONE: (314) FAX: PATIENT S NAME (LAST) (FIRST) (MI) SEX DATE OF BIRTH PATIENT S SS # PATIENT S ADDRESS PHONE REFERENCE # PATIENT S RELATIONSHIP TO RESPONSIBLE PARTY NAME OF RESPONSIBLE PARTY (IF DIFFERENT FROM PATIENT) MEDICAID # STATE MEDICARE # (INCLUDE PREFIX/SUFFIX) DIAGNOSIS REQUIRED 1-SELF 2-SPOUSE SOCIAL SECURITY (INSURED SS#): SUBSCRIBER / MEMBER # LOCATION GROUP # INSURANCE ADDRESS PHYSICIAN S PROVIDER # 3-CHILD 4-OTHER ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH 9 PRIMARY MEDICARE RETIREMENT OR DISABILITY 9 SECONDARY DATE: INSURANCE COMPANY NAME PLAN CARRIER CODE REGISTERED BY } EMPLOYER S NAME OR NUMBER WORKER S COMP 9 YES 9 NO MO/ILL REGIONAL SCREEN ROUTINE PROFILES 0.1 ml SERUM PER ALLERGEN ALLERGY TEST REQUEST PANELS (see back for details) FOOD SCREEN INDIVIDUAL ALLERGENS 0.1 ml SERUM PER ALLERGEN COMMON ALLERGENS GRASSES 9 g17 Bahia grass 9 G2 Bermuda grass 9 g11 Brome grass 9 g71 Canary grass 9 g3 Cocksfoot 9 g7 Common reed 9 g14 Cultivated oat 9 g12 Cultivated rye 9 G15 Cultivated wheat pollen 9 G10 Johnson grass 9 G8 June grass (Kent, blue) 9 G4 Meadow fescue 9 g16 Meadow foxtail 9 G5 Perennial rye grass 9 G9 Red top (Bent grass) 9 G1 Sweet vernal grass 9 G6 Timothy grass 9 g13 Velvet grass 9 g70 Wild rye grass BJ (09/18/13) Page 1 of 1 DRUGS 9 C1 Penicilloyl G 9 C2 Penicilloyl V 9 c5 Ampicilloyl 9 Rc209 Chymopapain EPIDERMAL / ANIMAL PRO. 9 e77 Budgerigar droppings 9 e78 Budgerigar feathers 9 e79 Budgerigar, serum proteins 9 E1 Cat dander 9 e4 Cow dander 9 E5 Dog dander 9 E2 Dog epithelium 9 e86 Duck feathers 9 e80 Goat epithelium 9 e70 Goose feathers 9 e6 Guinea pig epithelium 9 e84 Hamster epithelium 9 E3 Horse dander 9 e76 Mouse, serum proteins 9 e72 Mouse, urine proteins 9 e82 Rabbit epithelium 9 e75 Rat, serum proteins 9 e74 Rat, urine proteins 9 e81 Sheep epithelium 9 e83 Swine epithelium FOOD 9 f76 alpha-lactalbumin 9 F20 Almond 9 f49 Apple 9 f96 Avocado 9 f77 b-lactoglobulin 9 F45 Baker s yeast 9 F92 Banana 9 F6 Barley 9 f27 Beef 9 F256 Black Walnut 9 Rf288 Blueberry 9 F18 Brazil nut 9 F11 Buckwheat 9 f93 Cacao (Cocoa) 9 f202 Cashew 9 f31 Carrot 9 f78 Casein 9 F85 Celery 9 f81 Cheese cheddar type FOOD (Continued) 9 f82 Cheese, mould type 9 F83 Chicken meat 9 F36 Coconut 9 F3 Codfish 9 F1 Egg White 9 F75 Egg Yolk 9 F47 Garlic 9 Rf315 Green bean 9 f79 Gluten 9 Rf303 Halibut 9 F17 Hazel nut 9 f84 Kiwi fruit 9 Rf345 Macadamia Nut 9 f8 Maize 9 F91 Mango 9 F87 Melons 9 F2 Milk 9 f89 Mustard 9 f88 Mutton 9 F7 Oat 9 F33 Orange 9 f86 Parsley 9 f12 Pea 9 F13 Peanut 9 f201 Pecan 9 Rf253 Pinenut, pignoles 9 f203 Pistachio 9 f26 Pork 9 F35 Potato 9 Rf343 Raspberry 9 f9 Rice 9 F5 Rye 9 F41 Salmon 9 F10 Sesame seed 9 F14 Soybean 9 F44 Strawberry 9 k84 Sunflower seed 9 F25 Tomato 9 f204 Trout 9 F40 Tuna 9 f284 Turkey 9 F4 Wheat 9 f15 White beans HOUSE DUST 9 H1 House dust - Greer 9 H2 House dust - Hollister-Stier HOUSE DUST MITES 9 Dermatoph. Farinae 9 Dermatoph. Microceras 9 Dermatoph. Pteronyssimus INSECTS & VENOMS 9 Cockroach 9 Common wasp (yellow jacket) 9 Fire ant 9 Honey Bee 9 Paper wasp 9 White faced hornet 9 Yellow hornet MOLD 9 M6 Alternaria tenuis 9 M3 Aspergillus Fumigatus 9 m12 Aureobasidium pullulans 9 M7 Botrytis cinerea 9 m5 Candida albicans (yeast) 9 M2 Cladosporium Herbarium 9 m16 Curvularia lunata MOLD (Continued) 9 m14 Epicoccum purpurasen 9 M9 Fusarium moniliform 9 m9 Fusarium proliferatum 9 m4 Mucor racemosus 9 M1 Penicillium chrysogenum 9 M13 Phoma Betae 9 m11 Rhizopus nigricans 9 m8 Setomelanomma rostrata 9 m10 Stermphylium botryosum 9 m15 Trichoderma viride OCCUPATIONAL ALLERGENS 9 k82 Latex PARASITES AND INSECTS 9 p1 Ascaris 9 p2 Echinococcus 9 i71 Mosquito SHELL FISH 9 F37 Blue mussel 9 f207 Clams 9 F23 Crab 9 F80 Lobster 9 f290 Oysters 9 F24 Shrimp TREE POLLENS 9 t19 Acacia 9 t5 American beech 9 t73 Australian pine 9 Rt206 Chestnut 9 t3 Common silver birch 9 T14 Cottonwood, Poplar 9 Rt207 Douglas fir 9 Rt205 Elder tree 9 T8 Elm tree 9 t18 Eucalyptus, Gum-tree 9 t2 Grey alder 9 t4 Hazel 9 Rt209 Horn Beam 9 Rt208 Linden tree 9 T1 Maple (box elder) 9 t20 Mesquite 9 T6 Mountain juniper 9 t70 Mulberry 9 T7 Oak tree 9 t9 Olive TREE POLLENS (Continued) 9 T22 Pecan 9 Rt210 Privet 9 t72 Queen palm 9 Rt201 Spruce 9 t11 Sycamore, London plane 9 T10 Walnut tree 9 T15 White ash tree 9 T16 White pine tree 9 T12 Willow tree WEEDS 9 w13 Cocklebur 9 W1 Common ragweed (short) 9 w8 Dandelion 9 w9 English Plantain 9 wc4 False ragweed 9 W17 Firebrush (Kochia) 9 w3 Giant ragweed (tall) 9 w12 Golden Rod 9 W10 Lamb s quarters 9 w15 Lenscale 9 w6 Mugwort 9 w20 Nettle 9 w7 Ox-eye daisy 9 w16 Rough Marshelder 9 W14 Rough pigweed 9 w11 Russian thistle 9 w18 Sheep sorrel 9 w19 Wall pellitory 9 W2 Western ragweed 9 w5 Wormwood OTHER ALLERGENS:

2 MO/ILL REGIONAL SCREEN 14 TESTS Dermatoph. pteronyssimus Dermatoph. farinae House Dust - Hollister-Stier Cat Dander Dog Dander Bermuda Grass Rye Grass Timothy Cladosporium herbarum Alternaria tenuis Maple (Box Elder) Oak Elm Ragweed FOOD SCREEN - 11 TESTS Tuna Egg White Milk Orange Peanut Chicken Potato Sesame Soybean Tomato Wheat

3 Date} NAME ADDRESS ACCOUNT INFORMATION PHONE ORDERING PHYSICIAN BILL TO: 9 ACCOUNT 9 PATIENT/INSURANCE 9 ALTERNATE SEND ADDITIONAL COPY OF REPORT TO: CLIENT NUMBER/PHYSICIAN NAME PHONE/FAX NUM. PHYSICIAN S ADDRESS CITY, STATE, ZIP COLLECTION TIME FASTING COLLECTION DATE URINE hrs/vol : AM PM YES 9 NO 9 hrs vol STAT CALL RESULTS TO: COMPLETE AND (# ) ATTACH STAT FLYER BJH REGISTRATION # ALLERGEN TEST REQUEST FORM Department of Laboratories St. Louis, Missouri PATIENT RESP. PARTY INSURANCE PHONE: (314) FAX: PATIENT S NAME (LAST) (FIRST) (MI) SEX DATE OF BIRTH PATIENT S SS # PATIENT S ADDRESS PHONE REFERENCE # PATIENT S RELATIONSHIP TO RESPONSIBLE PARTY NAME OF RESPONSIBLE PARTY (IF DIFFERENT FROM PATIENT) MEDICAID # STATE MEDICARE # (INCLUDE PREFIX/SUFFIX) DIAGNOSIS REQUIRED 1-SELF 2-SPOUSE SOCIAL SECURITY (INSURED SS#): SUBSCRIBER / MEMBER # LOCATION GROUP # INSURANCE ADDRESS PHYSICIAN S PROVIDER # 3-CHILD 4-OTHER ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH 9 PRIMARY MEDICARE RETIREMENT OR DISABILITY 9 SECONDARY DATE: INSURANCE COMPANY NAME PLAN CARRIER CODE REGISTERED BY } EMPLOYER S NAME OR NUMBER WORKER S COMP 9 YES 9 NO MO/ILL REGIONAL SCREEN ROUTINE PROFILES 0.1 ml SERUM PER ALLERGEN ALLERGY TEST REQUEST PANELS (see back for details) FOOD SCREEN INDIVIDUAL ALLERGENS 0.1 ml SERUM PER ALLERGEN COMMON ALLERGENS GRASSES 9 g17 Bahia grass 9 G2 Bermuda grass 9 g11 Brome grass 9 g71 Canary grass 9 g3 Cocksfoot 9 g7 Common reed 9 g14 Cultivated oat 9 g12 Cultivated rye 9 G15 Cultivated wheat pollen 9 G10 Johnson grass 9 G8 June grass (Kent, blue) 9 G4 Meadow fescue 9 g16 Meadow foxtail 9 G5 Perennial rye grass 9 G9 Red top (Bent grass) 9 G1 Sweet vernal grass 9 G6 Timothy grass 9 g13 Velvet grass 9 g70 Wild rye grass BJ (09/18/13) Page 1 of 1 DRUGS 9 C1 Penicilloyl G 9 C2 Penicilloyl V 9 c5 Ampicilloyl 9 Rc209 Chymopapain EPIDERMAL / ANIMAL PRO. 9 e77 Budgerigar droppings 9 e78 Budgerigar feathers 9 e79 Budgerigar, serum proteins 9 E1 Cat dander 9 e4 Cow dander 9 E5 Dog dander 9 E2 Dog epithelium 9 e86 Duck feathers 9 e80 Goat epithelium 9 e70 Goose feathers 9 e6 Guinea pig epithelium 9 e84 Hamster epithelium 9 E3 Horse dander 9 e76 Mouse, serum proteins 9 e72 Mouse, urine proteins 9 e82 Rabbit epithelium 9 e75 Rat, serum proteins 9 e74 Rat, urine proteins 9 e81 Sheep epithelium 9 e83 Swine epithelium FOOD 9 f76 alpha-lactalbumin 9 F20 Almond 9 f49 Apple 9 f96 Avocado 9 f77 b-lactoglobulin 9 F45 Baker s yeast 9 F92 Banana 9 F6 Barley 9 f27 Beef 9 F256 Black Walnut 9 Rf288 Blueberry 9 F18 Brazil nut 9 F11 Buckwheat 9 f93 Cacao (Cocoa) 9 f202 Cashew 9 f31 Carrot 9 f78 Casein 9 F85 Celery 9 f81 Cheese cheddar type FOOD (Continued) 9 f82 Cheese, mould type 9 F83 Chicken meat 9 F36 Coconut 9 F3 Codfish 9 F1 Egg White 9 F75 Egg Yolk 9 F47 Garlic 9 Rf315 Green bean 9 f79 Gluten 9 Rf303 Halibut 9 F17 Hazel nut 9 f84 Kiwi fruit 9 Rf345 Macadamia Nut 9 f8 Maize 9 F91 Mango 9 F87 Melons 9 F2 Milk 9 f89 Mustard 9 f88 Mutton 9 F7 Oat 9 F33 Orange 9 f86 Parsley 9 f12 Pea 9 F13 Peanut 9 f201 Pecan 9 Rf253 Pinenut, pignoles 9 f203 Pistachio 9 f26 Pork 9 F35 Potato 9 Rf343 Raspberry 9 f9 Rice 9 F5 Rye 9 F41 Salmon 9 F10 Sesame seed 9 F14 Soybean 9 F44 Strawberry 9 k84 Sunflower seed 9 F25 Tomato 9 f204 Trout 9 F40 Tuna 9 f284 Turkey 9 F4 Wheat 9 f15 White beans HOUSE DUST 9 H1 House dust - Greer 9 H2 House dust - Hollister-Stier HOUSE DUST MITES 9 Dermatoph. Farinae 9 Dermatoph. Microceras 9 Dermatoph. Pteronyssimus INSECTS & VENOMS 9 Cockroach 9 Common wasp (yellow jacket) 9 Fire ant 9 Honey Bee 9 Paper wasp 9 White faced hornet 9 Yellow hornet MOLD 9 M6 Alternaria tenuis 9 M3 Aspergillus Fumigatus 9 m12 Aureobasidium pullulans 9 M7 Botrytis cinerea 9 m5 Candida albicans (yeast) 9 M2 Cladosporium Herbarium 9 m16 Curvularia lunata MOLD (Continued) 9 m14 Epicoccum purpurasen 9 M9 Fusarium moniliform 9 m9 Fusarium proliferatum 9 m4 Mucor racemosus 9 M1 Penicillium chrysogenum 9 M13 Phoma Betae 9 m11 Rhizopus nigricans 9 m8 Setomelanomma rostrata 9 m10 Stermphylium botryosum 9 m15 Trichoderma viride OCCUPATIONAL ALLERGENS 9 k82 Latex PARASITES AND INSECTS 9 p1 Ascaris 9 p2 Echinococcus 9 i71 Mosquito SHELL FISH 9 F37 Blue mussel 9 f207 Clams 9 F23 Crab 9 F80 Lobster 9 f290 Oysters 9 F24 Shrimp TREE POLLENS 9 t19 Acacia 9 t5 American beech 9 t73 Australian pine 9 Rt206 Chestnut 9 t3 Common silver birch 9 T14 Cottonwood, Poplar 9 Rt207 Douglas fir 9 Rt205 Elder tree 9 T8 Elm tree 9 t18 Eucalyptus, Gum-tree 9 t2 Grey alder 9 t4 Hazel 9 Rt209 Horn Beam 9 Rt208 Linden tree 9 T1 Maple (box elder) 9 t20 Mesquite 9 T6 Mountain juniper 9 t70 Mulberry 9 T7 Oak tree 9 t9 Olive TREE POLLENS (Continued) 9 T22 Pecan 9 Rt210 Privet 9 t72 Queen palm 9 Rt201 Spruce 9 t11 Sycamore, London plane 9 T10 Walnut tree 9 T15 White ash tree 9 T16 White pine tree 9 T12 Willow tree WEEDS 9 w13 Cocklebur 9 W1 Common ragweed (short) 9 w8 Dandelion 9 w9 English Plantain 9 wc4 False ragweed 9 W17 Firebrush (Kochia) 9 w3 Giant ragweed (tall) 9 w12 Golden Rod 9 W10 Lamb s quarters 9 w15 Lenscale 9 w6 Mugwort 9 w20 Nettle 9 w7 Ox-eye daisy 9 w16 Rough Marshelder 9 W14 Rough pigweed 9 w11 Russian thistle 9 w18 Sheep sorrel 9 w19 Wall pellitory 9 W2 Western ragweed 9 w5 Wormwood OTHER ALLERGENS:

4 MO/ILL REGIONAL SCREEN 14 TESTS Dermatoph. pteronyssimus Dermatoph. farinae House Dust - Hollister-Stier Cat Dander Dog Dander Bermuda Grass Rye Grass Timothy Cladosporium herbarum Alternaria tenuis Maple (Box Elder) Oak Elm Ragweed FOOD SCREEN - 11 TESTS Tuna Egg White Milk Orange Peanut Chicken Potato Sesame Soybean Tomato Wheat

5 Date} NAME ADDRESS ACCOUNT INFORMATION PHONE ORDERING PHYSICIAN BILL TO: 9 ACCOUNT 9 PATIENT/INSURANCE 9 ALTERNATE SEND ADDITIONAL COPY OF REPORT TO: CLIENT NUMBER/PHYSICIAN NAME PHONE/FAX NUM. PHYSICIAN S ADDRESS CITY, STATE, ZIP COLLECTION TIME FASTING COLLECTION DATE URINE hrs/vol : AM PM YES 9 NO 9 hrs vol STAT CALL RESULTS TO: COMPLETE AND (# ) ATTACH STAT FLYER BJH REGISTRATION # ALLERGEN TEST REQUEST FORM Department of Laboratories St. Louis, Missouri PATIENT RESP. PARTY INSURANCE PHONE: (314) FAX: PATIENT S NAME (LAST) (FIRST) (MI) SEX DATE OF BIRTH PATIENT S SS # PATIENT S ADDRESS PHONE REFERENCE # PATIENT S RELATIONSHIP TO RESPONSIBLE PARTY NAME OF RESPONSIBLE PARTY (IF DIFFERENT FROM PATIENT) MEDICAID # STATE MEDICARE # (INCLUDE PREFIX/SUFFIX) DIAGNOSIS REQUIRED 1-SELF 2-SPOUSE SOCIAL SECURITY (INSURED SS#): SUBSCRIBER / MEMBER # LOCATION GROUP # INSURANCE ADDRESS PHYSICIAN S PROVIDER # 3-CHILD 4-OTHER ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH 9 PRIMARY MEDICARE RETIREMENT OR DISABILITY 9 SECONDARY DATE: INSURANCE COMPANY NAME PLAN CARRIER CODE REGISTERED BY } EMPLOYER S NAME OR NUMBER WORKER S COMP 9 YES 9 NO MO/ILL REGIONAL SCREEN ROUTINE PROFILES 0.1 ml SERUM PER ALLERGEN ALLERGY TEST REQUEST PANELS (see back for details) FOOD SCREEN INDIVIDUAL ALLERGENS 0.1 ml SERUM PER ALLERGEN COMMON ALLERGENS GRASSES 9 g17 Bahia grass 9 G2 Bermuda grass 9 g11 Brome grass 9 g71 Canary grass 9 g3 Cocksfoot 9 g7 Common reed 9 g14 Cultivated oat 9 g12 Cultivated rye 9 G15 Cultivated wheat pollen 9 G10 Johnson grass 9 G8 June grass (Kent, blue) 9 G4 Meadow fescue 9 g16 Meadow foxtail 9 G5 Perennial rye grass 9 G9 Red top (Bent grass) 9 G1 Sweet vernal grass 9 G6 Timothy grass 9 g13 Velvet grass 9 g70 Wild rye grass BJ (09/18/13) Page 1 of 1 DRUGS 9 C1 Penicilloyl G 9 C2 Penicilloyl V 9 c5 Ampicilloyl 9 Rc209 Chymopapain EPIDERMAL / ANIMAL PRO. 9 e77 Budgerigar droppings 9 e78 Budgerigar feathers 9 e79 Budgerigar, serum proteins 9 E1 Cat dander 9 e4 Cow dander 9 E5 Dog dander 9 E2 Dog epithelium 9 e86 Duck feathers 9 e80 Goat epithelium 9 e70 Goose feathers 9 e6 Guinea pig epithelium 9 e84 Hamster epithelium 9 E3 Horse dander 9 e76 Mouse, serum proteins 9 e72 Mouse, urine proteins 9 e82 Rabbit epithelium 9 e75 Rat, serum proteins 9 e74 Rat, urine proteins 9 e81 Sheep epithelium 9 e83 Swine epithelium FOOD 9 f76 alpha-lactalbumin 9 F20 Almond 9 f49 Apple 9 f96 Avocado 9 f77 b-lactoglobulin 9 F45 Baker s yeast 9 F92 Banana 9 F6 Barley 9 f27 Beef 9 F256 Black Walnut 9 Rf288 Blueberry 9 F18 Brazil nut 9 F11 Buckwheat 9 f93 Cacao (Cocoa) 9 f202 Cashew 9 f31 Carrot 9 f78 Casein 9 F85 Celery 9 f81 Cheese cheddar type FOOD (Continued) 9 f82 Cheese, mould type 9 F83 Chicken meat 9 F36 Coconut 9 F3 Codfish 9 F1 Egg White 9 F75 Egg Yolk 9 F47 Garlic 9 Rf315 Green bean 9 f79 Gluten 9 Rf303 Halibut 9 F17 Hazel nut 9 f84 Kiwi fruit 9 Rf345 Macadamia Nut 9 f8 Maize 9 F91 Mango 9 F87 Melons 9 F2 Milk 9 f89 Mustard 9 f88 Mutton 9 F7 Oat 9 F33 Orange 9 f86 Parsley 9 f12 Pea 9 F13 Peanut 9 f201 Pecan 9 Rf253 Pinenut, pignoles 9 f203 Pistachio 9 f26 Pork 9 F35 Potato 9 Rf343 Raspberry 9 f9 Rice 9 F5 Rye 9 F41 Salmon 9 F10 Sesame seed 9 F14 Soybean 9 F44 Strawberry 9 k84 Sunflower seed 9 F25 Tomato 9 f204 Trout 9 F40 Tuna 9 f284 Turkey 9 F4 Wheat 9 f15 White beans HOUSE DUST 9 H1 House dust - Greer 9 H2 House dust - Hollister-Stier HOUSE DUST MITES 9 Dermatoph. Farinae 9 Dermatoph. Microceras 9 Dermatoph. Pteronyssimus INSECTS & VENOMS 9 Cockroach 9 Common wasp (yellow jacket) 9 Fire ant 9 Honey Bee 9 Paper wasp 9 White faced hornet 9 Yellow hornet MOLD 9 M6 Alternaria tenuis 9 M3 Aspergillus Fumigatus 9 m12 Aureobasidium pullulans 9 M7 Botrytis cinerea 9 m5 Candida albicans (yeast) 9 M2 Cladosporium Herbarium 9 m16 Curvularia lunata MOLD (Continued) 9 m14 Epicoccum purpurasen 9 M9 Fusarium moniliform 9 m9 Fusarium proliferatum 9 m4 Mucor racemosus 9 M1 Penicillium chrysogenum 9 M13 Phoma Betae 9 m11 Rhizopus nigricans 9 m8 Setomelanomma rostrata 9 m10 Stermphylium botryosum 9 m15 Trichoderma viride OCCUPATIONAL ALLERGENS 9 k82 Latex PARASITES AND INSECTS 9 p1 Ascaris 9 p2 Echinococcus 9 i71 Mosquito SHELL FISH 9 F37 Blue mussel 9 f207 Clams 9 F23 Crab 9 F80 Lobster 9 f290 Oysters 9 F24 Shrimp TREE POLLENS 9 t19 Acacia 9 t5 American beech 9 t73 Australian pine 9 Rt206 Chestnut 9 t3 Common silver birch 9 T14 Cottonwood, Poplar 9 Rt207 Douglas fir 9 Rt205 Elder tree 9 T8 Elm tree 9 t18 Eucalyptus, Gum-tree 9 t2 Grey alder 9 t4 Hazel 9 Rt209 Horn Beam 9 Rt208 Linden tree 9 T1 Maple (box elder) 9 t20 Mesquite 9 T6 Mountain juniper 9 t70 Mulberry 9 T7 Oak tree 9 t9 Olive TREE POLLENS (Continued) 9 T22 Pecan 9 Rt210 Privet 9 t72 Queen palm 9 Rt201 Spruce 9 t11 Sycamore, London plane 9 T10 Walnut tree 9 T15 White ash tree 9 T16 White pine tree 9 T12 Willow tree WEEDS 9 w13 Cocklebur 9 W1 Common ragweed (short) 9 w8 Dandelion 9 w9 English Plantain 9 wc4 False ragweed 9 W17 Firebrush (Kochia) 9 w3 Giant ragweed (tall) 9 w12 Golden Rod 9 W10 Lamb s quarters 9 w15 Lenscale 9 w6 Mugwort 9 w20 Nettle 9 w7 Ox-eye daisy 9 w16 Rough Marshelder 9 W14 Rough pigweed 9 w11 Russian thistle 9 w18 Sheep sorrel 9 w19 Wall pellitory 9 W2 Western ragweed 9 w5 Wormwood OTHER ALLERGENS:

6 MO/ILL REGIONAL SCREEN 14 TESTS Dermatoph. pteronyssimus Dermatoph. farinae House Dust - Hollister-Stier Cat Dander Dog Dander Bermuda Grass Rye Grass Timothy Cladosporium herbarum Alternaria tenuis Maple (Box Elder) Oak Elm Ragweed FOOD SCREEN - 11 TESTS Tuna Egg White Milk Orange Peanut Chicken Potato Sesame Soybean Tomato Wheat

7 Date} NAME ADDRESS ACCOUNT INFORMATION PHONE ORDERING PHYSICIAN BILL TO: 9 ACCOUNT 9 PATIENT/INSURANCE 9 ALTERNATE SEND ADDITIONAL COPY OF REPORT TO: CLIENT NUMBER/PHYSICIAN NAME PHONE/FAX NUM. PHYSICIAN S ADDRESS CITY, STATE, ZIP COLLECTION TIME FASTING COLLECTION DATE URINE hrs/vol : AM PM YES 9 NO 9 hrs vol STAT CALL RESULTS TO: COMPLETE AND (# ) ATTACH STAT FLYER BJH REGISTRATION # ALLERGEN TEST REQUEST FORM Department of Laboratories St. Louis, Missouri PATIENT RESP. PARTY INSURANCE PHONE: (314) FAX: PATIENT S NAME (LAST) (FIRST) (MI) SEX DATE OF BIRTH PATIENT S SS # PATIENT S ADDRESS PHONE REFERENCE # PATIENT S RELATIONSHIP TO RESPONSIBLE PARTY NAME OF RESPONSIBLE PARTY (IF DIFFERENT FROM PATIENT) MEDICAID # STATE MEDICARE # (INCLUDE PREFIX/SUFFIX) DIAGNOSIS REQUIRED 1-SELF 2-SPOUSE SOCIAL SECURITY (INSURED SS#): SUBSCRIBER / MEMBER # LOCATION GROUP # INSURANCE ADDRESS PHYSICIAN S PROVIDER # 3-CHILD 4-OTHER ADDRESS OF RESPONSIBLE PARTY APT # DATE OF BIRTH 9 PRIMARY MEDICARE RETIREMENT OR DISABILITY 9 SECONDARY DATE: INSURANCE COMPANY NAME PLAN CARRIER CODE REGISTERED BY } EMPLOYER S NAME OR NUMBER WORKER S COMP 9 YES 9 NO MO/ILL REGIONAL SCREEN ROUTINE PROFILES 0.1 ml SERUM PER ALLERGEN ALLERGY TEST REQUEST PANELS (see back for details) FOOD SCREEN INDIVIDUAL ALLERGENS 0.1 ml SERUM PER ALLERGEN COMMON ALLERGENS GRASSES 9 g17 Bahia grass 9 G2 Bermuda grass 9 g11 Brome grass 9 g71 Canary grass 9 g3 Cocksfoot 9 g7 Common reed 9 g14 Cultivated oat 9 g12 Cultivated rye 9 G15 Cultivated wheat pollen 9 G10 Johnson grass 9 G8 June grass (Kent, blue) 9 G4 Meadow fescue 9 g16 Meadow foxtail 9 G5 Perennial rye grass 9 G9 Red top (Bent grass) 9 G1 Sweet vernal grass 9 G6 Timothy grass 9 g13 Velvet grass 9 g70 Wild rye grass BJ (09/18/13) Page 1 of 1 DRUGS 9 C1 Penicilloyl G 9 C2 Penicilloyl V 9 c5 Ampicilloyl 9 Rc209 Chymopapain EPIDERMAL / ANIMAL PRO. 9 e77 Budgerigar droppings 9 e78 Budgerigar feathers 9 e79 Budgerigar, serum proteins 9 E1 Cat dander 9 e4 Cow dander 9 E5 Dog dander 9 E2 Dog epithelium 9 e86 Duck feathers 9 e80 Goat epithelium 9 e70 Goose feathers 9 e6 Guinea pig epithelium 9 e84 Hamster epithelium 9 E3 Horse dander 9 e76 Mouse, serum proteins 9 e72 Mouse, urine proteins 9 e82 Rabbit epithelium 9 e75 Rat, serum proteins 9 e74 Rat, urine proteins 9 e81 Sheep epithelium 9 e83 Swine epithelium FOOD 9 f76 alpha-lactalbumin 9 F20 Almond 9 f49 Apple 9 f96 Avocado 9 f77 b-lactoglobulin 9 F45 Baker s yeast 9 F92 Banana 9 F6 Barley 9 f27 Beef 9 F256 Black Walnut 9 Rf288 Blueberry 9 F18 Brazil nut 9 F11 Buckwheat 9 f93 Cacao (Cocoa) 9 f202 Cashew 9 f31 Carrot 9 f78 Casein 9 F85 Celery 9 f81 Cheese cheddar type FOOD (Continued) 9 f82 Cheese, mould type 9 F83 Chicken meat 9 F36 Coconut 9 F3 Codfish 9 F1 Egg White 9 F75 Egg Yolk 9 F47 Garlic 9 Rf315 Green bean 9 f79 Gluten 9 Rf303 Halibut 9 F17 Hazel nut 9 f84 Kiwi fruit 9 Rf345 Macadamia Nut 9 f8 Maize 9 F91 Mango 9 F87 Melons 9 F2 Milk 9 f89 Mustard 9 f88 Mutton 9 F7 Oat 9 F33 Orange 9 f86 Parsley 9 f12 Pea 9 F13 Peanut 9 f201 Pecan 9 Rf253 Pinenut, pignoles 9 f203 Pistachio 9 f26 Pork 9 F35 Potato 9 Rf343 Raspberry 9 f9 Rice 9 F5 Rye 9 F41 Salmon 9 F10 Sesame seed 9 F14 Soybean 9 F44 Strawberry 9 k84 Sunflower seed 9 F25 Tomato 9 f204 Trout 9 F40 Tuna 9 f284 Turkey 9 F4 Wheat 9 f15 White beans HOUSE DUST 9 H1 House dust - Greer 9 H2 House dust - Hollister-Stier HOUSE DUST MITES 9 Dermatoph. Farinae 9 Dermatoph. Microceras 9 Dermatoph. Pteronyssimus INSECTS & VENOMS 9 Cockroach 9 Common wasp (yellow jacket) 9 Fire ant 9 Honey Bee 9 Paper wasp 9 White faced hornet 9 Yellow hornet MOLD 9 M6 Alternaria tenuis 9 M3 Aspergillus Fumigatus 9 m12 Aureobasidium pullulans 9 M7 Botrytis cinerea 9 m5 Candida albicans (yeast) 9 M2 Cladosporium Herbarium 9 m16 Curvularia lunata MOLD (Continued) 9 m14 Epicoccum purpurasen 9 M9 Fusarium moniliform 9 m9 Fusarium proliferatum 9 m4 Mucor racemosus 9 M1 Penicillium chrysogenum 9 M13 Phoma Betae 9 m11 Rhizopus nigricans 9 m8 Setomelanomma rostrata 9 m10 Stermphylium botryosum 9 m15 Trichoderma viride OCCUPATIONAL ALLERGENS 9 k82 Latex PARASITES AND INSECTS 9 p1 Ascaris 9 p2 Echinococcus 9 i71 Mosquito SHELL FISH 9 F37 Blue mussel 9 f207 Clams 9 F23 Crab 9 F80 Lobster 9 f290 Oysters 9 F24 Shrimp TREE POLLENS 9 t19 Acacia 9 t5 American beech 9 t73 Australian pine 9 Rt206 Chestnut 9 t3 Common silver birch 9 T14 Cottonwood, Poplar 9 Rt207 Douglas fir 9 Rt205 Elder tree 9 T8 Elm tree 9 t18 Eucalyptus, Gum-tree 9 t2 Grey alder 9 t4 Hazel 9 Rt209 Horn Beam 9 Rt208 Linden tree 9 T1 Maple (box elder) 9 t20 Mesquite 9 T6 Mountain juniper 9 t70 Mulberry 9 T7 Oak tree 9 t9 Olive TREE POLLENS (Continued) 9 T22 Pecan 9 Rt210 Privet 9 t72 Queen palm 9 Rt201 Spruce 9 t11 Sycamore, London plane 9 T10 Walnut tree 9 T15 White ash tree 9 T16 White pine tree 9 T12 Willow tree WEEDS 9 w13 Cocklebur 9 W1 Common ragweed (short) 9 w8 Dandelion 9 w9 English Plantain 9 wc4 False ragweed 9 W17 Firebrush (Kochia) 9 w3 Giant ragweed (tall) 9 w12 Golden Rod 9 W10 Lamb s quarters 9 w15 Lenscale 9 w6 Mugwort 9 w20 Nettle 9 w7 Ox-eye daisy 9 w16 Rough Marshelder 9 W14 Rough pigweed 9 w11 Russian thistle 9 w18 Sheep sorrel 9 w19 Wall pellitory 9 W2 Western ragweed 9 w5 Wormwood OTHER ALLERGENS:

8 MO/ILL REGIONAL SCREEN 14 TESTS Dermatoph. pteronyssimus Dermatoph. farinae House Dust - Hollister-Stier Cat Dander Dog Dander Bermuda Grass Rye Grass Timothy Cladosporium herbarum Alternaria tenuis Maple (Box Elder) Oak Elm Ragweed FOOD SCREEN - 11 TESTS Tuna Egg White Milk Orange Peanut Chicken Potato Sesame Soybean Tomato Wheat