ࡱ> PRO  bjbj?? $]]ZEEEEEYYYY8 LY$  egggggggE!!%gEE|)FEEe!eEE`'PYo.0  E!!! :    Patient______________________________________________ Patch Testing Date & Time Applied Date & Time Removed Readings at 48 to 72 hoursDateInitialsDateInitialsTo Do #Antigen- CosmeticsIndurationErythemaScoreIndurationErythemaScore1Hydroquinone 1% 2Toluenesulphonamide Formaldehyde Resin 10%3Abitol 10% 4Compositae Mix 6% 5Benzyl Salicylate 1% 6Vanillin 10% 7Lemon Grass Oil 2% 8Balsam of Tolu 20% 9Cocamidopropylbetaine (in water) 1% 10Abietic Acid 10%11Sodium Benzoate 5%12Benzyl Alcohol 1%13Dexpanthenol 5% 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  FORMCHECKBOX  Avoid these areas: _______________________________________ Practice name Address State, City, Zip Phone: Fax: E-mail: 4/23/03 form developed  I L m n | } ~  hRdh/;<h/;<CJOJQJaJjt5hh_Ujhh_U hh_CJ hh_CJhh_7Eqr$If  !$If !$a$ hbbbbbbbbbb$Ifkd$$Iflֈ '-f30>54 laP              F J K L M N O P Q R S Ff FfVFf$IfS T V c d e f g h i j k l m o FfFf $If Ff*Fff$If        5 6 7 8 9 : ; Ff Ff$If; < = > ? 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