Skin Prick Testing Report

Patient: [Patient name; DOB; MRN]

Date of Service: [Date]

Ordering Clinician: [Name, credentials] (Only include if different from interpreting clinician)

Interpreting Clinician: [Name, credentials]

Indication & Clinical Context

[Chief symptoms prompting evaluation; suspected triggers and exposure context (home, pets, seasonal/occupational patterns); clinical question to be answered; relevant comorbidities impacting safety or interpretation; prior allergy testing results with dates if available] (Summarize concisely in a single paragraph. Include prior test modality and date only if explicitly stated.)

Procedure

• Procedure performed: Percutaneous skin prick testing
• Test site(s): [Forearm / back; laterality]
• Controls used: [Positive control type; negative control type]
• Reading interval: [Minutes from application to read]
• Measurement method: [Wheal diameter in mm; note whether flare recorded]
• Extract manufacturer and lot: [Manufacturer; lot numbers] (Include for traceability when available)
• Number of allergen extracts tested: [Count] (Count allergen extracts only; do not include positive or negative controls per CMS policy)

Controls & Validity

Positive control: [Wheal (mm)] / [Flare (mm)] (Include flare if recorded)

Negative control: [Wheal (mm)] / [Flare (mm)] (Include flare if recorded)

Validity: [Controls appropriate and results interpretable / Controls inadequate: (explanation and impact on interpretation) / Controls not documented and validity cannot be confirmed] (If negative control is reactive suggesting dermatographism or positive control is suppressed, document the limitation and whether results require cautious interpretation or repeat testing. If control results are not provided, state validity cannot be confirmed.)

Results

(Record actual millimeter measurements. Do not use +/++/+++ grades without corresponding mm values. If an allergen was planned but not tested, mark "Not tested" with reason. If a measurement is missing, mark "Not documented." Include only categories relevant to the testing performed.)

Allergen	Wheal (mm)	Flare (mm)	Interpretation	Comments
Trees
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]
Grasses
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]
Weeds
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]
Molds
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]
Dust Mites
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]
Animal Danders
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]
Foods
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]
Other
[Allergen name]	[mm / not documented]	[mm / not recorded]	[Positive / Negative / Borderline / Invalid / Not tested]	[Comments if applicable]

Summary: [1–3 sentence narrative of key positive sensitizations and notable negatives]

Interpretation

Test interpretation (sensitization): [Positivity criterion used (e.g., wheal ≥3 mm greater than negative control); list of allergens with positive results; note any invalid or borderline results] (Wheal size does not predict clinical severity of reactions.)

Clinical relevance assessment:

• [Allergen]: [Clinically relevant / Possibly relevant / Unclear relevance / Unlikely relevant] — [Rationale correlating symptoms, timing, and exposure]
• [Allergen]: [Clinically relevant / Possibly relevant / Unclear relevance / Unlikely relevant] — [Rationale]

(Sensitization does not equal clinical allergy. For food sensitizations, clinical correlation and potentially supervised oral food challenge are needed before diagnosing food allergy.)

Plan

• Allergen avoidance: [Targeted recommendations for clinically relevant sensitizations]
• Medications: [Continue / start / adjust pharmacotherapy as indicated]
• Allergen immunotherapy: [Candidate status based on clinically relevant aeroallergen sensitization and symptom burden; patient discussion] (Include only if immunotherapy was discussed)
• Further evaluation: [Additional history, environmental assessment, serum specific-IgE, or oral food challenge as indicated] (Include only if relevance is unclear or additional testing is planned)
• Repeat testing: [Plan for repeat skin testing or alternative modality] (Include only if testing validity was limited)
• Follow-up: [Timeframe and purpose]

Tolerance

[Tolerated procedure without complications / Adverse event occurred: signs/symptoms, timing, interventions (medications with doses/routes), response to treatment, observation duration]

Attestation

I personally reviewed and interpreted the skin prick testing results and discussed clinical significance and plan with the patient.

Interpreting Clinician Signature: [Name, credentials, date/time]