Form 57.75KK Laboratory Testing

1. Laboratory Testing

 

 

 

 

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	Serologic Test	Date	Result		Other Test	Date	Value
HIV	HIV EIA	____ / ____ / ______	P    N    I    R	Other Labs	ALT	____ / ____ / ______	_______ IU/L
	Confirmatory	____ / ____ / ______	P    N    I    R		Amylase	____ / ____ / ______	_______ IU/L
Hepatitis C	anti-HCV-EIA	____ / ____ / ______	P    N    I    R		Blood glucose	____ / ____ / ______	_______ mmol/L
	anti-HCV supp	____ / ____ / ______	P    N    I    R		Hematocrit	____ / ____ / ______	_______ %
	PCR HCV RNA	____ / ____ / ______	P    N    R		Hemoglobin	____ / ____ / ______	_______ gm/L
Hepatitis B	HBs Ag	____ / ____ / ______	P    N    R		Platelet	____ / ____ / ______	_______x 109/L
	IgM anti-HBc	____ / ____ / ______	P    N    R		# Blood cells in urine	____ / ____ / ______	_______ #/mm3
	Total anti-HBc	____ / ____ / ______	P    N    R		WBC	____ / ____ / ______	_______x 109/L
	anti-HBs	____ / ____ / ______	_______ mIU/mL		Creatinine	____ / ____ / ______	_______ µmol/L
					Other: _________	____ / ____ / ______	_______  _____

Serologic Test

Date

Result

Other Test

Date

Value

HIV

HIV EIA

____ / ____ / ______

P    N    I    R

Other Labs

ALT

____ / ____ / ______

_______ IU/L

Confirmatory

____ / ____ / ______

P    N    I    R

Amylase

____ / ____ / ______

_______ IU/L

Hepatitis C

anti-HCV-EIA

____ / ____ / ______

P    N    I    R

Blood glucose

____ / ____ / ______

_______ mmol/L

anti-HCV supp

____ / ____ / ______

P    N    I    R

Hematocrit

____ / ____ / ______

_______ %

PCR HCV RNA

____ / ____ / ______

P    N    R

Hemoglobin

____ / ____ / ______

_______ gm/L

Hepatitis B

HBs Ag

____ / ____ / ______

P    N    R

Platelet

____ / ____ / ______

_______x 109/L

IgM anti-HBc

____ / ____ / ______

P    N    R

# Blood cells in urine

____ / ____ / ______

_______ #/mm3

Total anti-HBc

____ / ____ / ______

P    N    R

WBC

____ / ____ / ______

_______x 109/L

anti-HBs

____ / ____ / ______

_______ mIU/m/L

Creatinine

____ / ____ / ______

_______ µmol/L

Other: _________

____ / ____ / ______

_______  _____