Thirty-Six Week (9 Month) Evaluation

Patient Name ______________________________________
 
Evaluation Date _________________________

Laboratory Studies

WBC (x 1000)
 
[ __ __.__ ]
Neutrophil count (%)
 
[ __ __ ] OR (x 1000) [ __ .__ __ ]
Hemoglobin (g/dl)
 
[ __ __.__ ]
Platelets (x 1000)
 
[ __ __ __ ]
Reticulocyte count (%)
 
[ __ .__ __ ] OR (10 9/l) [ __ __ . __ ]
AST (IU)
 
[ __ __ __ ]
ALT (IU)
 
[ __ __ __ ]
Alkaline Phosphatase (IU)
 
[ __ __ __ ]
Total Bilirubin (mg/dl)
 
[ __.__ ]
Serum Albumin (g/dl)
 
[ __.__ ]
Glucose (mg/dl)
 
[ __ __ __ ]
BUN (mg/dl)
 
[ __ __ ]
Serum Creatinine
 
[ __ .__ ]
TSH
 
[ __ __.__ ]
  Positive Negative
Urine or Serum Pregnancy Test
 
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Dose Reduction Permanent Discontinuation
Hemoglobin < 10 g/dl
In cardiac patients
>= 2g/dl decrease during any 4 week period.
Hemoglobin < 85 g/dl
In cardiac patients
< 12g/dl after 4 weeks of dose reduction.
WBC < 1.5 x 109/l WBC < 1.0 x 109/l
Neutrophil < 0.75 x 109/l Neutrophil < 0.5 x 109/l
Platelet Count < 50 x 109/l Platelet Count < 25 x 109/l
Moderate Depression Severe Depression

 
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