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)
|
[ __.__ ]
|
Prothrombin Time (seconds)
|
[ __ __.__ ]
|
Prothrombin Time INR
|
[ __.__ ]
|
Glucose (mg/dl)
|
[ __ __ __ ]
|
BUN (mg/dl)
|
[ __ __ ]
|
Serum Creatinine
|
[ __ .__ ]
|
TSH
|
[ __ __.__ ]
|
|
|
Positive
|
Negative
|
HCV-RNA PCR
|
|
|
Urine or Serum Pregnancy Test
|
|
|