CLINICAL PATHOLOGY WORKSHEET

Collection Information

Type of Restraint: Phys. Chemical Behav.

Date of Collection: Day______

Mo_______Yr______

Time of Collection:________:_________

Health Status: Normal Abnormal

Fasting Time: < 2 hours 24-48 hours 2-8 hours > 48 hours 8-16 hours 16-24 hours

Activity: very low low elev. highly elev.

variable indeterminate

Actual Weight:__________ kg lb gmCollection Site: Jugular Vein Femoral Artery Cephalic Vein Saphenous Vein Femoral Vein Ear Vein Cardiac Puncture Tail Vein Wing Vein Other

Person Collecting Sample:_____ ______ ______

Hematology Analysis Information

Date of Analysis: Day______ Mo______Yr_______

Time of Analysis:__________:___________

Time of Blood Smear:_________:_________

Laboratory:_______________________________Automated Analysis: Yes No

Person Performing:______ _______ _______

Additive EDTA Citrate Heparin Other___________ Oxalate Not recorded

Anticoagulant Form: Dry Liquid

Sample Clotted: Yes No

Diff Quik Wrights Giemsa May-Grumwald

Sample Appearance: Hemolytic Lipemic

Sample too small: Yes NoInitial Conditions: Ambient < 10 hours Chilled 10-24 hours Frozen 24-48 hours

>48 hours

Condition: not deteriorated deterioratedManual Differential: Yes No

Hematology Tests and ResultsWBC:__________ x 10(3)/mm(3)

RBC:___________ x 10(6)/mm(3)

HGB:___________gm/dl

HCT:___________%

Reticulocytes:___________%

Segmented Neutrophils:___________%________/mm(3)

Neutrophilic Bands:___________%___________/mm(3)

Lymphocytes:______________%_____________/mm(3)

Monocytes:________________%_____________/mm(3)

Eosinophils:________________%_____________/mm(3)

Basophils:_______________%_______________/mm(3)

Metamyelocytes:_____________%___________/mm(3)

Nucleated RBCs:_______________________/100 WBC

Azurophils:__________________%___________/mm(3)

Coarse Eos Granulocytes:__________%_______/mm(3)

Fine Eos Granulocytes:___________%_________/mm(3)

Platelet Estimate:___________________

Granulated Thrombocytes:________%________/mm(3)

Thrombocyte Estimate:__________________

Erythrocyte Sed Rate:________________/mm/hr

Total Protein (refractometer):______________mg/dl

Morphology Occ. Mild Mod Marked

1+ 2+ 3+ 4+AnisocytosisPoikilocytosisPolychromoasiaHowell-Jolly BodiesTarget CellsBasophilic StipplingHypochromisRouleaux Formation

RBC: Normal WBC: Normal WBC is estimate

Morphology Comments:_____________________________________________________________________________________________________________________________________________Reason for tests/Tests Requested:

Accession #____________________________________

Common Name:________________________________

ID #__________________________________________

CLINICAL PATHOLOGY WORKSHEET

Collection Information

Type of Restraint: Phys. Chemical Behav.

Date of Collection: Day______

Mo_______Yr______

Time of Collection:________:_________

Health Status: Normal Abnormal

Fasting Time: < 2 hours 24-48 hours 2-8 hours > 48 hours 8-16 hours 16-24 hours

Activity: very low low elev. highly elev.

variable indeterminate

Actual Weight:__________ kg lb gmCollection Site: Jugular Vein Femoral Artery Cephalic Vein Saphenous Vein Femoral Vein Ear Vein Cardiac Puncture Tail Vein Wing Vein Other

Person Collecting Sample:_____ ______ ______

Chemistry Analysis Information

Date of Analysis: Day______ Mo______Yr_______

Time of Analysis:__________:___________

Laboratory:_______________________________Automated Analysis: Yes No

Person Performing:______ _______ _______

Type of Sample: Serum Plasma Whole Blood

Anticoagulant: EDTA Citrate Heparin Other___________ Oxalate Not recorded

Anticoagulant Form: Dry Liquid

Sample Quality: Hemolytic Lipemia

Sample too small: Yes No

Initial Conditions: Ambient < 10 hours Chilled 10-24 hours Frozen 24-48 hours

>48 hours

Condition: not deteriorated deteriorated

Accession #______________________________

Common Name:_____________________________

ID #:____________________________________

Chemistry Tests and ResultsGlucsose:________________________mg/dl

BUN:___________________________mgdl

Creatinine:______________________mg/dl

Uric Acid:_______________________mg/dl

Calcium:________________________mg/dl

Phosphorus:_____________________mg/dl

Sodium:_________________________meq/dl

Potassium:_______________________meq/dl

Chloride:________________________meq/dl

CO2:____________________________MMOL/L

Alk Phos:________________________IU/L

AST (SGOT):_____________________IU/L

ALT (SGPT):_____________________IU/L

Cholestrol:_______________________mg/dl

Total Protein (C):__________________gm/dl

Total Protein (R):__________________gm/dl

Total Bilirubin:____________________mg/dl

GGT:____________________________IU/L

Amylase:_________________________IU/L

BUN/Creatinine Ratio:________________mg/dl

Albumin:__________________________g/dl

CK:______________________________U/L

Globulin:__________________________g/L

Alb/Glob Rato:____________________

Extra Chemistry

Tests:__________________________________

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Comments:___________________________________________

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