Request form-cast.xls

ALLERGY CAST REQUEST FORM
ALLERGOLOGY, DIAGNOSTIC & CLINICAL RESEARCH UNIT (ADCRU)
Tel: (021) 406-6889
UCT LUNG INSTITUTE
Fax: (021) 406-6888
Age/D.O.B: .….…/….…./….…….
Account To
Relevant Clinical Data:
Work Tel.No.:Home Tel.No.: Employer's Name: Time lapse since last adverse reaction:
Other: (specify) ……………………………………………………………………………………………………………………….………………….
PLEASE TICK AND INDICATE ALLERGENS REQUESTED :
ANTIBIOTICS:
ANALGESICS & ANTI-INFLAMMATORIES: FOOD ADDITIVES & COLOURANTS: ANAESTHETICS:
C5 1 Lys-aspirin
C1 0 3 Tartrazine
C AT R Atracurium
C5 2 Diclofenac
C1 1 1 Na benzoate
C MI V Mivacurium
C1 1 Benzylpenicil oyl
C5 3 Ibuprofen
C1 1 2 Na nitrite
C P AN Pancuronium
C2 0 3 Ampicil in
C5 4 Indomethacin
C1 1 3 Na-Metabisulphite C S UX Suxamethonium
C2 0 4 Amoxycil in
1C5 785 Acetaminophen
C1 1 4 Na salicylate
C R O C Rocuronium
C3 Cephalosporin C
1C5 8796 Mefenamic acid
C E1 0 4 Quinoline Yel ow
C VE C Vecuronium
C3 1 Cefamandole
12C5 9807 Phenylbutazone
C E1 1 0 Sunset Yel ow FCF CL I D Lidocaine
C3 2 Cefazolin
21C5 0918 Propylphenazone
C E1 2 2 Chromotrope B
CT H I Propofol
C6 1 Sulphamethoxazole 2C5 109 Dipyrone / Metamizole C E1 2 3 Amaranth
C6 2 Trimethoprin
C E1 2 4 New Coccine
C7 5 Tetracycline
C E1 2 7 Erythrosine
OCCUPATIONALS:
C8 1 Ciprofloxacin
C E1 3 1 Patent Blue V
2K8 102 Latex
4C3 63 Cefuroxime
C E1 3 2 Indigo carmine
C1 2 Minor 1 Determinant Mix
C E1 5 1 Bril iant Black
C1 0 1 Food Colourant Mix I (CE104, CE110, CE122, CE123, CE124)
C1 0 2 Food Colourant Mix II (CE127, CE131, CE132, CE151)
C E6 2 1 Glutamate
Patient to be taken off al al ergy medication 24 hours prior to blood col ection.
Please take 2 EDTA tubes (purple top).
Please take blood after 3pm and send to UCT Lung Institute via Pathcare N1 City to arrive the next morning.
Please send on ice and wrap specimens in paper towel or bubble wrap to prevent damage to blood cel s.

Source: http://lunginstitute.co.za/downloads/cast_request.pdf