LABORATORY ORDER FORM FOR BLOOD TESTS
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LABORATORY
ORDER FORM |
Name: |
Birthdate: |
Date: |
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Diagnosis:
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Insurance: |
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CHEMISTRY |
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Glucose |
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BUN |
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Creatinine |
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Sodium |
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Potassium |
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Chloride |
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Carbon Dioxide |
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Calcium |
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Phosphorus |
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Uric Acid |
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Bilirubin Total |
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Bilirubin Direct |
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Alkaline Phosphatase |
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SGOT (AST) |
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SGPT (ALT) |
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LDH |
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CHolesterol |
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Total Protein |
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Albumin |
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Triglyceride |
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HDL Cholesterol |
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Iron |
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Unbound Iron |
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Protein Electrophoresis |
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Amylase |
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Acid Phosphatase |
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Magnesium |
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CK |
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GGT |
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Serum Osmolality |
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Acetone |
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Neonatal Total Bilirubin |
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Neonatal Direct Bilitrubin |
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C Reactive Protein--
Quantitative |
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HEMATOLOGY
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CBC |
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C10 |
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Sickle cell |
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Fetal HgB |
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Westergren ESR |
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Retic Count |
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Eosinophil Count |
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LAP |
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Glyco HgB |
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COAGULATION |
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Patient Receiving Anticoagulants?
__Y? __N?
__Coumadin?
__Heparin?
__Other?
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Prothrombin Time |
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Activated PTT |
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Fibrinogen |
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FDP |
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Bleeding Time |
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DRUGS |
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Date/Time of last dose
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ANTI-CONVULSANT |
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Tegretol |
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Phenobarbital |
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Dilantin |
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Mysoline |
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Depakene |
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ANTIBIOTICS |
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Gentamicin Peak |
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Gentamicin Trough |
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Tobramicin Peak |
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Tobramicin Trough |
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Vancomycin Peak |
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Vancomycin Trough |
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RADIOASSAY |
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T4 |
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T3 Uptake |
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TSH |
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Tree Thyroxine Index |
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Free T4 |
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Vitamin B12Folate |
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Ferritin |
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HCG Quantitative |
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Hepatitis B Surface Antigen |
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Hepatitis B Surface Antibody |
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HCV |
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Anti HBc (Core) |
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HIV-1 |
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HTLV-1 |
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PSA |
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Cortisol |
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Prolactin |
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LH |
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FSH |
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MISCELLANEOUS |
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Digoxin |
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Quinidine |
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Procainamide |
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NAPA |
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Ammonia |
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Lactic Acid |
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Ethyl Alcohol |
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Salicylate |
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Acetaminophen |
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Barb Screen |
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Benzoidiazepine Screen |
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Tricyclic screen |
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Lithium |
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Theophyline |
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OTHER |
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| PROFILE |
TESTS
INCLUDED |
| Electrolytes |
Na, K, Cl, CO2 |
| Chem-7 |
Glucose, BUN, Creatinine, Electrolytes |
| Chem Screen A (CSA) |
Glucose, BUN, Ca, P, Uric Acid, Alk Phos, Total Bili,
Direct Bili, Total Protein, Albumin, Globulin, Electrolytes, A/G
Ratio, Creatinine, Cholesterol, SGOT, SGPT, LDH |
| Chem Screen B (CSB) |
Ca, P, Uric Acid, Alk Phos, Total Bili, Direct Bili,
Total Protein, Albumin, Globulin, A/G Ratio, Cholesterol, SGPT,
SGPT, LDH |
| Liver Profile (LP) |
Alk Phos, Total Bili, Direct Bili, SGOT, SGPT, Total
Protein, Albumin, Globulin, A/G Ratio |
| Renal Profile (RP) |
BUN, Creatinine, Uric Acid, Ca, P, K |
| Care Panel (CARE) |
Cholesterol, Triglycerides, HDL, Chol/HDL Risk=Factor,
LDL |
| Thyroid Profile |
T3 Uptake, T4, T4 Iodine, TSH |
ABOUT
NS121 | ASSIGNMENTS | STUDENT
INFO | CASES |HELP/RESOURCES
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