Laboratory Tests - NINDS Common Data Elements



Lab Panel TableLab Panel: (check one) Date CollectedAccession Number: FORMCHECKBOX CHEMISTRY FORMCHECKBOX HEMATOLOGY FORMCHECKBOX URINALYSIS FORMCHECKBOX Other, specify: (M M/D D/Y Y Y Y):Accession Number:Indicate the appropriate result for each test.Lipid Laboratory TestsLipid Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Total Cholesterol (TCHOL)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownLow Density Lipoprotein (LDL)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownHigh Density Lipoprotein (HDL)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownTriglycerides (TGs)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownVery Low Density Lipoprotein (VLDL)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownLipoprotein(a) [Lp(a)]Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownApolipoprotein A-I (apo A1)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownApolipoprotein B (apo B)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownApolipoprotein E (apo E)Data to be entered by site FORMCHECKBOX APOE ε2 (rare) FORMCHECKBOX APOE ε3 (most common) FORMCHECKBOX APOE ε4 (high risk) N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownComplete Blood Count (CBC) Laboratory TestsComplete Blood Count (CBC) Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?White Blood Cell Count (WBC)Data to be entered by sitex10^3 FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownLymphocyte CountData to be entered by sitethousand/microL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownNeutrophil Count (PMNs)Data to be entered by sitethousand/microL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownMonocyte CountData to be entered by sitethousand/microL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownEosinophil CountData to be entered by sitethousand/microL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownHematocrit (HCT)Data to be entered by site% FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownHemoglobin (HB)Data to be entered by siteg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownPlatelet CountData to be entered by sitex10^3 FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownHemoglobin ElectrophoresisData to be entered by site FORMCHECKBOX Hemoglobin F (fetal hemoglobin) (HbF) FORMCHECKBOX Hemoglobin A (HbA) FORMCHECKBOX Hemoglobin A2 (HbA2) FORMCHECKBOX Hemoglobin S (HbS) FORMCHECKBOX Hemoglobin C (HbC) FORMCHECKBOX Hemoglobin E (HbE) FORMCHECKBOX Hemoglobin D (HbD) FORMCHECKBOX Hemoglobin H (heavy hemoglobin) (HbH)N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownElectrolyte Laboratory TestsElectrolyte Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Sodium (Na+)Data to be entered by sitemEq/L OR mg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownPotassium (K+)Data to be entered by sitemEq/L OR mg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownChloride (Cl-)Data to be entered by sitemEq/L OR mg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCarbon Dioxide (CO2)Data to be entered by sitemEq/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAnion GapData to be entered by sitemEq/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownBlood Urea Nitrogen (BUN)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCreatinineData to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownGlucoseData to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownFasting InsulinData to be entered by siteμIU/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownMagnesium (Mg2+)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownPhosphate (PO4)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCalcium (Ca2+)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownIonized Calcium (iCa2+)Data to be entered by sitemmol/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownBicarbonate (HCO3)Data to be entered by siteMeq/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownArterial Blood Gas Laboratory TestsArterial Blood Gas Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Partial Pressure of Oxygen (PaO2)Data to be entered by sitemmHg FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownPartial Pressure of Carbon Dioxide (PaCO2)Data to be entered by sitemmHg FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAcidity/ pHData to be entered by siteNumeric value FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownLiver Function Laboratory TestsLiver Function Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?AlbuminData to be entered by siteg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownTotal ProteinData to be entered by siteg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAspartate aminotransferase (AST)Data to be entered by siteunits/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAlanine Aminotransferase (ALT)Data to be entered by siteunits/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownTotal BilirubinData to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownDirect BilirubinData to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAlkaline PhosphataseData to be entered by siteunits/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownGamma-glutamyl transpeptidase (GGT)Data to be entered by siteunits/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownMiscellaneous Chemistry Laboratory TestsMiscellaneous Chemistry Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Lactate Dehydrogenase (LDH)Data to be entered by siteunits/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownLactateData to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownIronData to be entered by site?g/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownTotal Iron Binding Capacity (TIBC)Data to be entered by site?g/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownFerritinData to be entered by siteng/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAutoimmune Laboratory TestsAutoimmune Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Antinuclear Antibodies (ANA)Data to be entered by site FORMCHECKBOX Negative FORMCHECKBOX Positive (with numeric value, if positive)N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownClassical AntiNeutrophil Cytoplasmic Antibodies (C-ANCA)Data to be entered by site FORMCHECKBOX Negative FORMCHECKBOX Positive (with numeric value, if positive)N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownProtoplasmic-staining AntiNeutrophil Cytoplasmic Antibodies (P-ANCA)Data to be entered by site FORMCHECKBOX Negative FORMCHECKBOX Positive (with numeric value, if positive)N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownRheumatoid FactorData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX Positive (with numeric value, if positive) FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAnticardiolipin Antibody IgM (ACA Igm)Data to be entered by siteMPL units/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAnticardiolipin Antibody IgG (ACA IgG)Data to be entered by siteGPL units/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknownβ 2- glycoprotein Antibody IgMData to be entered by siteNumeric value FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX Unknownβ 2- glycoprotein Antibody IgGData to be entered by siteNumeric value FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownClotting Laboratory TestsClotting Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Factor V Leiden Mutation (FVL)Data to be entered by site FORMCHECKBOX Absent FORMCHECKBOX Heterozygous (1 allele) FORMCHECKBOX Homozygous (2 alleles)N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownProthrombin Gene Mutation (Factor II/ G20210A)Data to be entered by site FORMCHECKBOX Absent FORMCHECKBOX Heterozygous (1 allele) FORMCHECKBOX Homozygous (2 alleles)N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownProtein C ActivityData to be entered by site% FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownProtein S ActivityData to be entered by site% FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownProtein S Antigen, FreeData to be entered by site% FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownActivated Protein C Resistance (APCR)Data to be entered by siteratio FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownProthrombin Time (PT)Data to be entered by siteseconds FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownActivated Partial Thromboplastin Time (aPTT)Data to be entered by siteseconds FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAntithrombin Activity (AT-III)Data to be entered by site% FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownInternational Normalized Ratio (INR)Data to be entered by siteNumeric value FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownDilute Russell Viper Venom Time (DRVVT)Data to be entered by siteseconds FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownConfirmatory Testing for Lupus AnticoagulantData to be entered by siteratio FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownFibrinogenData to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownPlasminData to be entered by siteNumeric value FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownD-dimerData to be entered by siteng/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownThrombin TimeData to be entered by siteseconds FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownInflammatory Laboratory TestsInflammatory Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?High Sensitivity C Reactive Protein (hsCRP)Data to be entered by sitemg/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownErythrocyte Sedimentation Rate (ESR)Data to be entered by sitemm/hr FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownNutrition Laboratory TestsNutrition Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Vitamin B12Data to be entered by sitepg/ml FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownHomocysteineData to be entered by siteumol/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownFolateData to be entered by siteng/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownInfectious Disease Laboratory TestsInfectious Disease Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Rapid Plasma Reagin (RPR)Data to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownHIV AntibodiesData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCardiac Laboratory TestsCardiac Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Troponin IData to be entered by siteng/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownTroponin TData to be entered by siteng/mL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCreatine KinaseData to be entered by siteunits/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCreatine Kinase - Myocardial Bands (CK-MB)Data to be entered by siteU/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCerebral Spinal Fluid (CSF) Laboratory TestsCerebral Spinal Fluid (CSF) Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?CSF ProteinData to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCSF GlucoseData to be entered by siteng/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCSF White Blood Cell Count (WBC)Data to be entered by siteuL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCSF Red Blood Cell Count (RBC)Data to be entered by siteuL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownVenereal Disease Research Laboratory (VDRL) Slide TestData to be entered by site FORMCHECKBOX Nonreactive FORMCHECKBOX Weakly reactive FORMCHECKBOX Reactive (with quantitation)N/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownImmunoglobulin G (IgG)Data to be entered by sitemg/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownOligoclonal BandsData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownVaricella-Zoster Virus (VZV) AntibodiesData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX Equivocal FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownVaricella-Zoster Virus (VZV) PCRData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownMiscellaneous Laboratory TestsMiscellaneous Laboratory Tests TableTestResultUnits for ResultUnit TypeWas test result abnormal?Glycosylated Hemoglobin (HgbA1C)Data to be entered by site% FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownCreatinine ClearanceData to be entered by sitemL/minute FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownGlomerular Filtration Rate (GFR)Data to be entered by sitemL/min/1.73m2 FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownStool GuaiacData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAmmonia (NH3)Data to be entered by siteug of nitrogen/dL FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAmylaseData to be entered by siteunits/L FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownOther, specify:Data to be entered by siteData to be entered by site FORMCHECKBOX Standard FORMCHECKBOX SI FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownToxicology Screen ResultsToxicology Screen Results TableDrugResultUnits for ResultUnit TypeWas test result abnormal?AnalgesicsData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownAnticonvulsantsData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownBarbituratesData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownPsychotropicsData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownSedativesData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownStimulantsData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownSympathomimeticsData to be entered by site FORMCHECKBOX Negative FORMCHECKBOX PositiveN/A FORMCHECKBOX Normal FORMCHECKBOX Abnormal FORMCHECKBOX UnknownPregnancy TestWas a pregnancy test performed? FORMCHECKBOX Yes FORMCHECKBOX No (STOP) FORMCHECKBOX Not applicable Reason Test N/A: FORMCHECKBOX Post-Menopausal FORMCHECKBOX Surgically sterile FORMCHECKBOX Non-surgically sterile FORMCHECKBOX Male Date Performed (m m/d d/y y y y): 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.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 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. 5,10 Methylene Tetra Hydrofolate Reductase (MTHFR) is no longer recommended as a first line test. Homocysteine is preferred.Result – Record the numeric or alpha-numeric results for each laboratory test.Unit for Result – The recommended units for the numeric results for each laboratory test. For some laboratory tests, result option are included. See the data dictionary for additional information on coding the unit of measure using Unified Code for Units of Measure (UCUM).Unit Type – Choose one. Indicate if SI or Standard Units were used.Abnormal Result – Choose one. Indicate if the laboratory test result is abnormal. Abnormal means the test result falls outside the normal range. ................
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