LABORATORY ORDER FORM FOR BLOOD TESTS
LABORATORY
ORDER FORM |
Name: |
Birthdate: |
Date: |
Diagnosis:
|
Insurance: |
CHEMISTRY |
|
Glucose |
|
BUN |
|
Creatinine |
|
Sodium |
|
Potassium |
|
Chloride |
|
Carbon Dioxide |
|
Calcium |
|
Phosphorus |
|
Uric Acid |
|
Bilirubin Total |
|
Bilirubin Direct |
|
Alkaline Phosphatase |
|
SGOT (AST) |
|
SGPT (ALT) |
|
LDH |
|
CHolesterol |
|
Total Protein |
|
Albumin |
|
Triglyceride |
|
HDL Cholesterol |
|
Iron |
|
Unbound Iron |
|
Protein Electrophoresis |
|
Amylase |
|
Acid Phosphatase |
|
Magnesium |
|
CK |
|
GGT |
|
Serum Osmolality |
|
Acetone |
|
Neonatal Total Bilirubin |
|
Neonatal Direct Bilitrubin |
|
C Reactive Protein--
Quantitative |
|
|
|
|
HEMATOLOGY
|
|
CBC |
|
C10 |
|
Sickle cell |
|
Fetal HgB |
|
Westergren ESR |
|
Retic Count |
|
Eosinophil Count |
|
LAP |
|
Glyco HgB |
COAGULATION |
Patient Receiving Anticoagulants?
__Y? __N?
__Coumadin?
__Heparin?
__Other?
|
|
Prothrombin Time |
|
Activated PTT |
|
Fibrinogen |
|
FDP |
|
Bleeding Time |
DRUGS |
Date/Time of last dose
|
ANTI-CONVULSANT |
|
Tegretol |
|
Phenobarbital |
|
Dilantin |
|
Mysoline |
|
Depakene |
ANTIBIOTICS |
|
Gentamicin Peak |
|
Gentamicin Trough |
|
Tobramicin Peak |
|
Tobramicin Trough |
|
Vancomycin Peak |
|
Vancomycin Trough |
|
RADIOASSAY |
|
T4 |
|
T3 Uptake |
|
TSH |
|
Tree Thyroxine Index |
|
Free T4 |
|
Vitamin B12Folate |
|
Ferritin |
|
HCG Quantitative |
|
Hepatitis B Surface Antigen |
|
Hepatitis B Surface Antibody |
|
HCV |
|
Anti HBc (Core) |
|
HIV-1 |
|
HTLV-1 |
|
PSA |
|
Cortisol |
|
Prolactin |
|
LH |
|
FSH |
MISCELLANEOUS |
|
Digoxin |
|
Quinidine |
|
Procainamide |
|
NAPA |
|
Ammonia |
|
Lactic Acid |
|
Ethyl Alcohol |
|
Salicylate |
|
Acetaminophen |
|
Barb Screen |
|
Benzoidiazepine Screen |
|
Tricyclic screen |
|
Lithium |
|
Theophyline |
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
|