Colorwatch report form.qtxt

Colorwatch For VOLUNTARY reporting of adverse (migration) or
allergic reactions to pigments used in permanent makeup.
The AAM Safety Information and Adverse Event Reporting Program Mail to: PARR, 1087 Keolu Drive, Kailua, HI 96734
DClient ID
PARR: Pigment Adverse Reaction Report
A. Technician Information / Identifier
Phone Number
B. Patient (Client) Information
G. Suspected Pigment(s) / Inks: (list each pigment used)
Manufacturer
Doctors(s) Name(s) / Phone Number (s) / Specialty
C. Location of Adverse Reaction: (check all that apply)
H. Relevant Test / Biopsies / Lab Data (including dates)
❑ Eyebrow
❑ Cheeks
❑ Scratch Test Positive
❑ Granuloma with pigment
❑ Eyeliner
❑ Breast
❑ Body (below neck)
❑ Tissue Biopsy (Punch Biopsy)
❑ Other:
❑ Dr. Diagnosis (no biopsy)
D. Sensitivity “Spot” Test: (check all that apply)
❑ Yes
❑ Positive
❑ Waived
Treatments Attempted: (check all that apply)
❑ Negative
❑ Location:
❑ Kenalog® Injection Into Area
❑ Decadron Ophthalmic
E. Description of Adverse Reaction:
Overtattoo: Kenalog®
Cortisone Pills/Shots
(check all that apply)
❑ Overtattoo: Salt Solution
❑ Surgery
❑ Bleeding
❑ Burning
❑ Overtattoo: Chemicals (acids)
❑ Dermabrasion
Swelling/Fluid
❑ Dryness/Flaking ❑ Tender to touch
❑ Protopic (Elidel) or Aldara®
❑ Laser: LP Erbium or CO2
Skin Raised/
❑ Bumps in skin
❑ Scabbing
Puff Paint
❑ Cream: Steroid or Kenalog®
❑ Laser: Other (describe)
❑ Infection
❑ Cracking
❑ Migration
Current Status: (check all that apply)
Describe Event or Problem: Send Pictures if Possible
❑ Undergoing Treatment
❑ Lawsuit v. Technician
❑ Disability
❑ Lawsuit v. Manufacturer
❑ Disfigurement
❑ Reported to Insurance Co.
❑ Problem better
❑ Other (Describe)
❑ Problem worse
❑ Problem Ongoing
K. Final Diagnosis and Outcome
L. Reporter (check all that apply)
Reporter Name
Reporter Address
Reported To: (check all that apply)
Manufacturer
❑ Distributor
M. Health Care Professional
Check this box if you do NOT want your
❑ identity disclosed to the manufacturer
❑ No Occupation

Source: http://www.micropigmentation.org/allergic_reactions/Colorwatch_Report.pdf