Form: Bone Marrow Aspirate
| Question | Response |
|---|---|
| Specimen Material Type | |
| Date of assessment | |
| Specimen Condition | |
| Differential Cell Count | |
| Number of Cells Counted | |
| Percent Myeloblasts (%) | |
| Percent Promyelocytes (%) | |
| Percent Myelocytes (%) | |
| Percent Mature Granulocytes (%) | |
| Percent Erythroid Cells (%) | |
| Percent Monocytes (%) | |
| Percent Eosinophils (%) | |
| M:E Ratio | |
| Percent lymphocytes (%) |
Form: Laboratory Chemistry
| Question | Response |
|---|---|
| Date Collected | |
| Time Collected | |
| Was Sample Collected in a Fasti | |
| Potassium | |
| Sodium | |
| Chloride | |
| Bicarbonate | |
| Total Protein | |
| Albumin | |
| Calcium | |
| Magnesium | |
| Phosphorus | |
| Urea Nitrogen | |
| Urea | |
| Creatinine | |
| Total Bilirubin | |
| Direct Bilirubin | |
| Lipase | |
| Amylase | |
| LDH | |
| AST | |
| ALT | |
| Cholesterol | |
| HDL | |
| LDL | |
| Triglyceride | |
| GGT | |
| Derived Parameters: | |
| Glomerular Filtration Rate | |
| Estimated Creatinine Clearance | |
| Calcium Corrected | |
| Cholesterol/HDL-Cholesterol |
Form: Lab Coagulation
| Question | Response |
|---|---|
| Date Collected | |
| Time Collected | |
| Was Sample Collected in a Fasti | |
| Prothrombin Time | |
| International Normalized Ratio | |
| Fibrinogen | |
| Fibrin Split Product | |
| Fibrin D-Dimer |
Form: Laboratory Hematology
| Question | Response |
|---|---|
| Date Collected | |
| Time Collected | |
| Was Sample Collected in a Fasti | |
| RBC | |
| HGB | |
| HCT | |
| MCV | |
| MCH | |
| MCHC | |
| RDW | |
| Reticulocytes | |
| Platelets | |
| WBC | |
| Total Neutrophils | |
| Segmented Neutrophils | |
| Bands/Stabs | |
| Granulocytes | |
| Eosinophils | |
| Basophils | |
| Lymphocytes | |
| Monocytes | |
| Mid Cell Fraction | |
| Myeloblasts | |
| Promyelocytes | |
| Myelocytes | |
| Metamyelocytes | |
| Atypical Lymphocytes | |
| Blasts | |
| Nucleated RBC | |
| Derived parameters: | |
| Calculated Absolute Neutrophil |
Form: Pregnancy Test
| Question | Response |
|---|---|
| Form Not Done | |
| Reason Pregnancy Test Not Done | |
| If 'OTHER', specify | |
| If Test Performed, | |
| Date sample taken | |
| Specimen | |
| Result of pregnancy test |
Form: Lab Urinalysis
| Question | Response |
|---|---|
| Date Collected | |
| Time Collected | |
| Was Sample Collected in a Fasti | |
| Specific Gravity | |
| pH | |
| Calcium Urine | |
| Creatinine Urine | |
| Calcium Urine (24 hr) | |
| Creatinine Urine (24 hr) | |
| Derived parameters: | |
| Urine Calcium Creatinine Ratio | |
| Urine Calcium Creatinine Ratio | |
| Blood | |
| Protein | |
| Glucose | |
| Bilirubin | |
| WBC Urine | |
| RBC Urine | |
| Epithelial Cells Urine | |
| Bacteria Urine | |
| Casts Urine | |
| Crystals Urine | |