Results of biochemical analysis
Fill in results of creatinine testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of alanine amino-transferase testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Results of haematology analysis
Fill in results of lymphocytes testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of eosinophils testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of neutrophils testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of monocytes testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of basophils testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of red blood cells testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of haematocrit testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Fill in results of platelets testing. Answer 'ND' for not done, 'BSI' for blood sample inadequate for testing.
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Antibody determination
If YES, please complete date of blood sample taking below (if different from visit date). 5ml for biochemical and haematological analysis. 5 ml for HPV antibody determination.
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Please fill in, only if the date of blood sample taking for antibody determination is different from visit date.
date