CELL MORPHOLOGY INFORMATION FORM

Patient Name __________________________________________________         

Birthdate _______________Sex ____    Location:_____________________

Specimen Collected Date _____________ Time _____________________

Physician/Provider_________________________ Phone: _______________________

Diagnosis; Clinical findings:__________________________________________________

Reason for Cell Morphology:                    

______   Pancytopenia                                        _______ Physician ordered

______   Thrombocytopenia and/or Leukopenia        _______ Tech ordered

______   Thrombocytosis and/or Leukocytosis

______   WBC morphology abnormal

______   Suspect Blasts

______   Decreased HGB/HCT/RBC

______   Significant RBC morphology

______   NRBC's present

______   Blood Parasite suspected.   If so, please complete the following:

              Parasite suspected _____________________________________________

              Country patient visited ________________________________________

              Patient symptoms _______________________________________________

              Other __________________________________________________________

______   Other.   Please provide as much information as possible.

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