Vir-Sp-000-F3 - Laboratory Test Request For Service Sample And Consent Form
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1
2LABORATORY TEST REQUEST FOR SERVICE SAMPLE and CONSENT FORM
Virology Department, USAMC-AFRIMS
315/6 Rajvithi Road Bangkok 10400, Thailand TEL: 662-6445644 FAX: 662-6444760
All Laboratory data relevant to patient care will be provided to the physician. All patient identifiers will be removed following final disposition
►Patient/Subject general and history Information
Referring Hospital ________________________________________________________ Country _______________________________________________________
U.S.Embassy Medical Unit
Patient address (House number and street are not required) __________________________________________________________________________________
____________________________
Age ___________ (Years)_________ (Months)
Gender
Male
Female
Occupation
______________________
__________________________
Date of Admission
N/A
Date of illness onset
(DD/MM/YY)
(DD/MM/YY)
Symptoms
Current
Describe
Symptoms
Current
Describe
Symptoms
Current
Describe
o
Fever
Y N
Unk
Temp ____
C Vomiting
Y N Unk
Diarrhea
Y N Unk
Chills
Y N
Unk
Loss of appetite
Y N Unk
Seizure
Y N Unk
Headache
Y N
Unk
Abdominal pain
Y N Unk
Stiff neck
Y N Unk
Runny nose
Y N
Unk
Muscle/body pain
Y N Unk
Abnormal movement
Y N Unk
Sore throat
Y N
Unk
Joint pain
Y N Unk
Dark urine
Y N Unk
Cough
Y N
Unk
Malaise/fatigue
Y N Unk
Jaundice
Y N Unk
Nausea
Y N
Unk
Bleeding
Y N Unk
Mental status change
Y N Unk
Eye pain
Y N
Unk
Skin Rash
Y N Unk
Shortness of breath
Y N Unk
Others
The Result of Rapid Diagnostic Test:_________
Travel history prior illness
No
Yes, Travel to: ______________________________________ Duration (2weeks-2months) ___________
Direct exposure to animals
No
Yes, Poultry
Yes, Swine
Yes, Other (specify)_______________________________________________
Influenza vaccine within the last 12 months
No
Yes
Similar illness in family members
No
Yes
Provisional Diagnosis: _______________________
►Laboratory Test Request:
Dengue( EIA, IgG/IgM)
Japanese Encephalitis( EIA, IgG/IgM)
Influenza
X
Hepatitis HAV
Anti-HEV (IgG)
Anti-HEV (IgM)
Anti-HEV (Total Ig)
HBV
Anti-HBc (IgG or IgM)
Anti-HBc (Total Ig)
HBsAg
Anti-HBs
HCV
Anti-HCV (IgG)
HEV
Anti-HEV (IgG)
Anti-HEV (IgM)
Anti-HEV (Total Ig)
Others_______________________
Requested by (Print name)______________________________
► Type of specimen
For pre-printed label
Subject Number: ___________________________________________
Assigned by (initials):__________________________________
st
Whole blood / serum / plasma
Date Collected of 1
specimen ______________ Specimen Number_________________________
nd
Whole blood / serum / plasma
Date Collected of 2
specimen ______________ Specimen Number_________________________
CSF
Date Collected ____________________________ Specimen Number_________________________
Throat/Nasal swab
Date Collected _____________________________ Specimen Number_________________________
X
Other ________________________ Date Collected _____________________________ Specimen Number_________________________
Personnel information
Subject Name____________________________________________________ Hospital no. ______________ Admission no. _______________
N/A
N/A
N/A
VIR-SP-000-F3
Page 1 of 2
27 May 08
FOR OFFICIAL USE ONLY
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