PatientInitials
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Patient Initials
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ReportDate
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Report Date
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Is more than one laboratory used by your site for the patient?
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Code List
Is more than one laboratory used by your site for the patient?
If"Yes",thenameofthelaboratorythatisused.
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If "Yes", the name of the laboratory that is used.
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Is this an initial report by your site for the patient?
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Code List
Is this an initial report by your site for the patient?
If"No",dateofchange.
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If "No", date of change.
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Hemoglobinfrom(g/dl)
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Hemoglobin from (g/dl)
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Hemaoglobinto(g/dl)
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Hemaoglobin to (g/dl)
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Hematocritfrom(%)
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Hematocrit from (%)
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Hematocritto(%)
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Hematocrit to (%)
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WBCfrom(1000/cumm)
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WBC from (1000/cu mm)
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WBCto(1000/cumm)
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WBC to (1000/cu mm)
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Neutrophils(includingsBands)from(%)
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Neutrophils (includings Bands) from (%)
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Neutrophils(includingsBands)to(%)
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Neutrophils (includings Bands) to (%)
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AbsoluteNeutrophilCount(1000/cumm)WBCx(%NeutrophilsincludingBands)/100from
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Absolute Neutrophil Count (1000/cu mm) WBC x (%Neutrophils including Bands)/100 from
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AbsoluteNeutrophilCount(1000/cumm)WBCx(%NeutrophilsincludingBands)/100to
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Absolute Neutrophil Count (1000/cu mm) WBC x (%Neutrophils including Bands)/100 to
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Lymphocytesfrom(%)
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Lymphocytes from (%)
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Lymphocytesto(%)
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Lymphocytes to (%)
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Monocytesfrom(%)
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Monocytes from (%)
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Monocytesto(%)
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Monocytes to (%)
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Eosinophilsfrom(%)
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Eosinophils from (%)
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Eosinophilsto(%)
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Eosinophils to (%)
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Basophilsfrom(%)
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Basophils from (%)
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Basophilsto(%)
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Basophils to (%)
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Otherfrom(%)
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Other from (%)
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Otherto(%)
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Other to (%)
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Otherspecify
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Other specify
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Plateletsfrom(1000/cumm)
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Platelets from (1000/cu mm)
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Plateletsto(1000/cumm)
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Platelets to (1000/cu mm)
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RBCfrom(cmm)
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RBC from (cmm)
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RBCto(ccm)
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RBC to (ccm)
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Reticulocytecountfrom(%)
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Reticulocyte count from (%)
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Reticulocytecountto(%)
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Reticulocyte count to (%)
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PT(ProthrombinTime)from
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PT (Prothrombin Time) from
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PT(ProthrombinTime)to
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PT (Prothrombin Time) to
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PTT(PartialThromboplastinTime)from
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PTT (Partial Thromboplastin Time) from
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PTT(PartialThromboplastinTime)to
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PTT (Partial Thromboplastin Time) to
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Otherhematologytestfrom
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Other hematology test from
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Otherhematologytestto
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Other hematology test to
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Otherhematologytest,specify
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Other hematology test, specify
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OtherhematologytestUnits,specify
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Other hematology test Units, specify
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Sodiumfrom(mEq/L)
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Sodium from (mEq/L)
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Sodiumto(mEq/L)
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Sodium to (mEq/L)
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Potassiumfrom(mEq/L)
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Potassium from (mEq/L)
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Potassiumto(mEq/L)
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Potassium to (mEq/L)
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Chloridefrom(mEq/L)
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Chloride from (mEq/L)
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Chlorideto(mEq/L)
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Chloride to (mEq/L)
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Calciumfrom(mg/dl)
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Calcium from (mg/dl)
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Calciumto(mg/dl)
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Calcium to (mg/dl)
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Magnesiumfrom(mg/dl)
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Magnesium from (mg/dl)
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Magnesiumto(mg/dl)
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Magnesium to (mg/dl)
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Phosphorousfrom(mg/dl)
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Phosphorous from (mg/dl)
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Phosphorousto(mg/dl)
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Phosphorous to (mg/dl)
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CO2(Bicarbonate)from(mEq/L)
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CO2 (Bicarbonate) from (mEq/L)
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CO2(Bicarbonate)to(mEq/L)
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CO2 (Bicarbonate) to (mEq/L)
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AlkalinePhosphatasefrom(mU/ml)
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Alkaline Phosphatase from (mU/ml)
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AlkalinePhosphataseto(mU/ml)
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Alkaline Phosphatase to (mU/ml)
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SGOT(AST)from(mU/ml)
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SGOT (AST) from (mU/ml)
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SGOT(AST)to(mU/ml)
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SGOT (AST) to (mU/ml)
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SGPT(ALT)from(mU/ml)
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SGPT (ALT) from (mU/ml)
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SGPT(ALT)to(mU/ml)
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SGPT (ALT) to (mU/ml)
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LDH(LacticDehydrogenase)from(mU/ml)
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LDH (Lactic Dehydrogenase) from (mU/ml)
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LDH(LacticDehydrogenase)to(mU/ml)
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LDH (Lactic Dehydrogenase) to (mU/ml)
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UreaNitrogen(BUN)from(mg/dl)
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Urea Nitrogen (BUN) from (mg/dl)
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UreaNitrogen(BUN)to(mg/dl)
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Urea Nitrogen (BUN) to (mg/dl)
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Creatininefrom(mg/dl)
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Creatinine from (mg/dl)
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Creatinineto(mg/dl)
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Creatinine to (mg/dl)
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UricAcidfrom(mg/dl)
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Uric Acid from (mg/dl)
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UricAcidto(mg/dl)
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Uric Acid to (mg/dl)
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Glucosefrom(mg/dl)
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Glucose from (mg/dl)
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Glucoseto(mg/dl)
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Glucose to (mg/dl)
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TotalBilirubinfrom(mg/dl)
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Total Bilirubin from (mg/dl)
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TotalBilirubinto(mg/dl)
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Total Bilirubin to (mg/dl)
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TotalProteinfrom(mg/dl)
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Total Protein from (mg/dl)
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TotalProteinto(mg/dl)
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Total Protein to (mg/dl)
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Albuminfrom(g/dl)
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Albumin from (g/dl)
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Albuminto(g/dl)
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Albumin to (g/dl)
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Globulinfrom(g/dl)
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Globulin from (g/dl)
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Globulinto(g/dl)
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Globulin to (g/dl)
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Lipasefrom(U/L)
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Lipase from (U/L)
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Lipaseto(U/L)
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Lipase to (U/L)
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Amylasefrom(U/L)
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Amylase from (U/L)
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Amylaseto(U/L)
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Amylase to (U/L)
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CPK(CreatininePhosphokinase)from(U/L)
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CPK (Creatinine Phosphokinase) from (U/L)
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CPK(CreatininePhosphokinase)to(U/L)
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CPK (Creatinine Phosphokinase) to (U/L)
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TotalTriglyceridesfrom(mg/dl)
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Total Triglycerides from (mg/dl)
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TotalTriglyceridesto(mg/dl)
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Total Triglycerides to (mg/dl)
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LDLfrom(mg/dl)
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LDL from (mg/dl)
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LDLto(mg/dl)
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LDL to (mg/dl)
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HDLfrom(mg/dl)
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HDL from (mg/dl)
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HDLto(mg/dl)
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HDL to (mg/dl)
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TotalCholesterolfrom(mg/dl)
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Total Cholesterol from (mg/dl)
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TotalCholesterolto(mg/dl)
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Total Cholesterol to (mg/dl)
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Otherchemistrytestfrom
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Other chemistry test from
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Otherchemistrytestto
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Other chemistry test to
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Otherchemistrytestspecify
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Other chemistry test specify
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OtherchemistrytestUnits,specify
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Other chemistry test Units, specify
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