Forty-Eight Week (12 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)
 
[ __.__ ]
Prothrombin Time (seconds)
 
[ __ __.__ ]
Prothrombin Time INR
 
[ __.__ ]
Glucose (mg/dl)
 
[ __ __ __ ]
BUN (mg/dl)
 
[ __ __ ]
Serum Creatinine
 
[ __ .__ ]
TSH
 
[ __ __.__ ]
  Positive Negative
HCV-RNA PCR
 
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Urine or Serum Pregnancy Test
 
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