Testing Order Form

PATIENT INFORMATION
Patient’s full name; ______________________ MR number: _________________

Today’s date ____________ Date of Birth ____________ Age (yrs) _______

Gender _________________ Phone ______________ Mobile _______________

Primary insurance _______________ Secondary insurance _________________

REASON FOR TESTING

Reason for testing / Specific question(s) to be answered:
1. ____________________________________________________________
2. ____________________________________________________________

History / Allergies / Symptoms / Potential diagnosis / Special needs:___________

_________________________________________________________________
☐Check here if additional clinical information is included with this request.

SERVICES REQUESTED
HEMATOLOGY/BIOCHEMISTRY CARDIOLOGY
☐CBC ☐ Holter Monitor
☐ LFT ☐ Tilt Test
☐ ESR ☐ Event Monitor
☐ WBCs ☐ Exercise Testing (GXT)
☐ Hb ☐ with PFT 1
☐ Hct ☐ EKG
☐ RBCs ☐ With Rhythm Strip
☐ Plt ☐ With Signal Average
☐ FBS ☐ ECHO
☐ OGTT ☐ Pre-cath
☐ HBA1C ☐ Pre-surgery
☐ Urea ☐ Dobutamine
☐ BUN ☐ Other _________________
☐ Creatinine
☐ Electrolytes NEUROLOGY
☐ Cystatin-C EEG
☐ Calcium EEG, Sleep deprived
☐ TSH
☐ T3 PEDIATRIC REHABILITATION
☐ T4 EMG (indicate extremity
☐ Others: _____________________ _____________)
PULMONARY FUNCTION
☐Spirometry – evaluate for obstruction OTHERS
☐ give albuterol 2.5 mg nebulized only if baseline test ☐ DXA Scan
abnormal (spirometry) ☐ MRI Scan (specify complete
☐ give albuterol 2.5 mg nebulized regardless of baseline area _____________________)
test results (spirometry pre/post)
☐ Bone Mineral Density –
☐ Lung volumes (plethysmography)
Necessary to determine restriction ☐ Lumbar Spine
☐ Diffusion capacity (DLco) ☐ Body Composition-Total
Evaluate for abnormal gas exchange (may be seen in Body
interstitial lung disease) ☐ Sweat Chloride
Includes measurement of Hgb – requires CBC same day ☐ Other __________________
☐ Respiratory Muscle Strength
Evaluate for respiratory muscle weakness
☐ Methacholine Challenge
Evaluate for bronchial hyperreactivity/asthma
☐ Exercise Challenge
Evaluate for exercise-induced bronchospasm
Albuterol 2.5 mg nebulized prn in response to abnormal
test
☐ Exercise Challenge with EKG
Evaluate for exercise-induced bronchospasm and/or
exercise induced arrhythmia
Albuterol 2.5 mg nebulized prn in response to abnormal
test
☐Other_______________________________

REQUESTING PRACTITIONER / GROUP

Office Name ___________________ Ordering Physician’s Name:
____________

Office Address ____________________________________________________

Telephone ________________________ Fax ____________________________

Signature / Credentials of ordering Practitioner ______________ Date _________

Print Name (if different from physician above _____________________________