Albador AM Packet M/W Analyzer

Albador AM Advanced Medicine
Packet M/W Analyzer

PERSONAL DATA MANAGEMENT STATEMENT
The information that is provided will remain strictly confidential.
It will be used exclusively by Albador AM experts to establish your health condition.

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1/2. PATIENT'S PERSONAL DATA

Select Albador AM Packet *Albador AM Packet MAlbador AM Packet W

Name *

First

Middle

Last

Gender *MaleFemaleOther

Birthday Day/Month/Year *

Country *

City *

Postal Code

Postal Address 1

Postal Address 2 (optional)

House Number

Email Address *

Phone TypeMobileLandlineOther

Country Phone Code

Phone Number

Insurance Company

Insurance Number

Height / cm *

Weight / kg *

HAEMATOLOGICAL EXAMINATIONS

Leukocytes *

Erythrocytes *

Hemoglobin *

Hematocrit *

MCV *

MCH *

MCHC *

RDW *

Platelets *

MPV *

Sedimentation *

DKS – ANALYZER

Neutrophils *

Lymphocytes *

Monocytes *

Eosinophils *

Basophils *

Neutrophils % *

Lymphocytes % *

Monocytes % *

Eosinophils % *

Basophils % *

BIOCHEMICAL TESTS

AST *

ALT *

Gamma-GT *

A-phosphatase *

CK *

LDH *

Amylase *

Lipase *

Bili-Total *

Bili-Direct *

Urea *

Creatinine *

CKD-EPI *

Urate *

Glucose *

Cholesterol *

Triglycerides *

HDL-cholesterol *

LDL-cholesterol *

Iron *

Ferritin *

Potassium *

Sodium *

Chlorides *

Calcium *

Phosphate *

Magnesium *

Proteins (Required only for Packet M)

Albumini (Required only for Packet M)

CRP *

HbA1c % (Required only for Packet M)

HbA1c (Required only for Packet M)

URINALYSIS

Rel. Density *

Proteins *

Leukocytes *

(25-OH) Company PATIENT'S

Crystals *

pH *

Glucose *

Nitrites *

Ketones *

Urobilinogen *

Bilirubin *

Sediment *

Sediment Squamous Epithelium (Only for Packet M)

IMMUNOLOGICAL TESTS (Method: CMlA-Abbott)

TSH *

FT4 (Required only for Packet M)

FT3 (Required only for Packet M)

TPSA (Required only for Packet M)

CA 19-9 *

CA 125 (Required only for Packet W)

CEA *

CA 15-3 (Required only for Packet W)

Testosterone (Required only for Packet M)

Alpha Fetoprotein *

Cortisol *

Vitamin B12 (Required only for Packet M)

Folic acid (Required only for Packet M)

Vitamin D (25-OH) *

List of medications the patient is taking *

Other information about the patient that may be relevant prior to testing

Satisfaction Rating of this Analyses Order (0 = low, 10 = high)

Selected Value: 0

Consent to Medical purposes *

• By submitting this Albador AM Advanced Medicine – Packet M/W Analyzer, I agree to the use of personal information for medical purposes.

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