Laboratory Tests



Table SEQ Table \* ARABIC 1 Lab PanelLab Panel: (check one)Date Collected:Accession Number: FORMCHECKBOX CHEMISTRY FORMCHECKBOX HEMATOLOGY FORMCHECKBOX URINALYSIS FORMCHECKBOX Other, specify:Time Collected: FORMCHECKBOX AM FORMCHECKBOX PM FORMCHECKBOX 24-hr clockData to be filled out by siteIndicate the appropriate result for each testLipid Laboratory TestsTable SEQ Table \* ARABIC 2 Lipid Laboratory TestsTestResultUnits for ResultWas test result abnormal?If abnormal, Clinically Significant?Total Cholesterol (TCHOL)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantLow Density Lipoprotein (LDL)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantHigh Density Lipoprotein (HDL)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTriglycerides (TGs)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantVery Low Density Lipoprotein (VLDL)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantLipoprotein(a) [Lp(a)] TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantApolipoprotein A-I (apo A1)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantApolipoprotein B (apo B)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantApolipoprotein E (apo E)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantComplete Blood Count (CBC) Laboratory TestsTable SEQ Table \* ARABIC 3 Complete Blood Count (CBC) Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?White Blood Cell Count (WBC)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantLymphocyte Count TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantNeutrophil Count (PMNs)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantMonocyte CountTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantEosinophil CountTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantHematocrit (HCT)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantHemoglobin (HB)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantPlatelet CountTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantHemoglobin ElectrophoresisTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantElectrolyte Laboratory TestsTable SEQ Table \* ARABIC 4 Electrolyte Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Sodium (Na+)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantPotassium (K+)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantChloride (Cl-)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCarbon Dioxide (CO2)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAnion GapTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantBlood Urea Nitrogen (BUN)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCreatinineTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantGlucoseTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantMagnesium (Mg2+)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantPhosphate (PO4)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCalcium (Ca2+)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantIonized Calcium (iCa2+)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Bicarbonate (HCO3)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantArterial Blood Gas Laboratory TestsTable SEQ Table \* ARABIC 5 Arterial Blood Gas Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Partial Pressure of Oxygen (PaO2)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantPartial Pressure of Carbon Dioxide (PaCO2)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAcidity/ pHTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantLiver Function Laboratory TestsTable SEQ Table \* ARABIC 6 Liver Function Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?AlbuminTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTotal ProteinTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAspartate aminotransferase (AST)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAlanine Aminotransferase (ALT)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTotal BilirubinTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantDirect BilirubinTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Alkaline PhosphataseTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantMiscellaneous Chemistry Laboratory TestsTable 7 Miscellaneous Chemistry Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Lactate Dehydrogenase (LDH)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantLactateTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantIronTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTotal Iron Binding Capacity (TIBC)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantFerritinTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTable 8 Autoimmune Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Antinuclear Antibodies (ANA)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantClassical AntiNeutrophil Cytoplasmic Antibodies (C-ANCA)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantProtoplasmic-staining AntiNeutrophil Cytoplasmic Antibodies (P-ANCA)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantRheumatoid FactorTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAnticardiolipin Antibody IgM (ACA Igm)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAnticardiolipin Antibody IgG (ACA IgG)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantβ 2- glycoprotein Antibody IgMTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantβ 2- glycoprotein Antibody IgGTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantClotting Laboratory TestsTable 9 Clotting Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Factor V Leiden Mutation (FVL)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantProthrombin Gene Mutation (Factor II/ G20210A)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantProtein C ActivityTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantProtein S ActivityTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantActivated Protein C Resistance (APCR)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significant5,10 Methylene Tetra Hydrofolate Reductase (MTHFR)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantProthrombin Time (PT)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantActivated Partial Thromboplastin Time (aPTT)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAntithrombin Activity (AT-III)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantInternational Normalized Ratio (INR)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantDilute Russell Viper Venom Time (DRVVT)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantConfirmatory Testing for Lupus Anticoagulant TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantFibrinogenTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantPlasminTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantD-dimerTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantThrombin TimeTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantInflammatory Laboratory TestsTable 10 Inflammatory Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?High Sensitivity C Reactive Protein (hsCRP)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantErythrocyte Sedimentation Rate (ESR)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantNutrition Laboratory TestsTable 11 Nutrition Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Vitamin B12TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantHomocysteineTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantFolateTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significant25-hydroxy Vitamin DTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantInfectious Disease Laboratory TestsTable 12 Infectious Disease Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Rapid Plasma Reagin (RPR)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantHIV AntibodiesTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCardiac Laboratory TestsTable 13 Cardiac Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Troponin ITBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantTroponin TTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCreatine KinaseTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCreatine Kinase - Myocardial Bands (CK-MB)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCerebral Spinal Fluid (CSF) Laboratory TestsTable 14 Cerebral Spinal Fluid (CSF) Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?CSF ProteinTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCSF GlucoseTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCSF White Blood Cell Count (WBC)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCSF Red Blood Cell Count (RBC)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantVenereal Disease Research Laboratory (VDRL) Slide TestTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantMiscellaneous Laboratory TestsTable 15 Miscellaneous Laboratory TestsTestResultUnit for ResultWas test result abnormal?If abnormal, Clinically Significant?Glycosylated Hemoglobin (HgbA1C)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantCreatinine ClearanceTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantGlomerular Filtration Rate (GFR)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantStool GuaiacTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantToxicology ScreenTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAmmonia (NH3)TBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantAmylaseTBDTBD FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknown FORMCHECKBOX Clinically significant FORMCHECKBOX Not clinically significantPregnancy TestWas a pregnancy test performed? FORMCHECKBOX Yes FORMCHECKBOX No (STOP) FORMCHECKBOX Not applicableReason Test N/A: FORMCHECKBOX Post-Menopausal FORMCHECKBOX Surgically sterile FORMCHECKBOX Non-surgically sterile FORMCHECKBOX MaleDate Performed: Test Type: FORMCHECKBOX Blood FORMCHECKBOX UrineResult: FORMCHECKBOX Positive FORMCHECKBOX NegativeGeneral InstructionsLaboratory tests are routinely administered in clinical trials of pharmacological interventions to assess subject safety. Laboratory tests may also be used to determine an individual’s eligibility for a study. None of the data elements included on this CRF are considered Core (i.e., strongly recommended for all studies to collect). These data elements are Exploratory and should be collected for clinical trials when the research team considers them appropriate for their study. Laboratory results may be received via electronic files directly from central study laboratories or recorded manually on case report forms if the study is using a local lab. In either scenario, it is recommended that the Laboratory Test form be used to record when samples were collected (date and time) so that the laboratory tests results can be matched with the samples collected for each subject.Specific InstructionsPlease see the Laboratory Tests and Vital Signs for SCI spreadsheet for proposed reference ranges for the tests included on this form.Please see the Data Dictionary for definitions for each of the data elements included in this CRF Module.Lab Panel – Choose the lab panel that was performed.Date and Time Collected –Record the date (and time) the specimen was collected. The date/time should be recorded to the level of granularity known (e.g., year, year and month, complete date plus hours and minutes, etc.) and in the format acceptable to the study database.Accession Number – Provide the accession number or bar code number that is assigned to the specimen.Test – Indicate the name of each laboratory test that is run on the specimen. See the data dictionary for additional information on coding the test name using Logical Observation Identifiers Names and Codes (LOINC).Test Performed – Choose one. Indicate whether or not the test was performed on the specimen.Result – Record the numeric or alpha-numeric results for each laboratory test.Unit for Result – Record the units the numeric results for each laboratory test are measured in. See the data dictionary for additional information on coding the unit of measure using Unified Code for Units of Measure (UCUM).Abnormal Result – Choose one. Indicate if the laboratory test result is abnormal. Abnormal means the test result falls outside the normal range.Clinical Significance – Choose one. If the laboratory test result is abnormal, indicate if the physician considers the result clinically significant. ................
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