Sample Patient Information Form

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Follow-up Activity for:
HbA1c does not always estimate average glucose. Behan, KJ ; Merschen,J. Clinical
Laboratory Science, 2011 Spring; 24(2): 71-7
Name
_________________________________________________
Date
_________________________________________________
Hours to Complete
_________________________________________________
For patients in your facility, record the HbA1C result and the average (fasting and postprandial) glucose in the chart below and plot them on the graph showing the
expected correlation between HbA1C and estimate average glucose (eAG). Flag the results that do not correlate well and record the HbA1C method used. Do
these patient records indicate the presence of variant forms of hemoglobin?
HbA1C
eAG
Patient
flag
Method used
%
mmol/L

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