Q23-34: Hematologic Findings Prior to the Preparative Regimen (Conditioning)

*Infusion Without a Preparative Regimen
Complete questions 23-34 based on the most recent testing prior to infusion if no preparative regimen was given.

Question 23: Date CBC tested: (testing within 30 days of start of preparative regimen)

These questions are intended to determine the clinical status of the recipient prior to the preparative regimen for stem cell transplantation. Testing may be performed multiple times within the pre-transplant work-up time period; report the most recent CBC obtained. Laboratory values obtained on the first day of the preparative regimen may be reported as long as the blood was drawn before any radiation or systemic therapy was administered.

Questions 24-33: Provide last laboratory values recorded just prior to preparative regimen:

For each value below, indicate if the result was “known” or “unknown” prior to the start of the preparative regimen. Indicate the units for each test, taking care to convert them to a unit available on the form, if necessary.

WBC: The white blood cell count is a value that represents all of the white blood cells in the blood. If the count is too high or too low, the ability to fight infection may be impaired.

Neutrophils: Neutrophils are a subtype of white blood cell that fights infection. The value on the laboratory report may be a percentage or an absolute value. If an absolute value is reported, divide it by the white blood cell count for a percentage. Neutrophils are also known as polymorphonuclear leukocytes (PMNs).

Lymphocytes: Lymphocytes are another subtype of white blood cell that fights infection. The value on the laboratory report may be a percentage of an absolute value. If an absolute value is reported, divide it by the white blood cell count for a percentage.

Hemoglobin: Hemoglobin is a molecule in red blood cells that delivers oxygen to tissues throughout the body. A low hemoglobin count is considered “anemia” and blood transfusions or growth factors may be required to increase the hemoglobin level. Also indicate if the recipient received a red blood cell transfusion within 30 days prior to testing.

Hematocrit: The hematocrit is the percentage (sometimes displayed as a proportion) of red blood cells relative to the total blood volume. A low hematocrit may require red blood cell transfusions or growth factors. Indicate if the recipient received a red blood cell transfusion within 30 days prior to testing.

Platelets: Platelets are formed elements within the blood that help with coagulation. A low platelet count, called thrombocytopenia, may lead to easy bleeding or bruising. Thrombocytopenia may require platelet transfusions. Indicate if the recipient received a platelet transfusion within 7 days prior to testing.

Question 34: Was RBC transfused ≤ 30 days before date of test?

Indicate if the recipient received a red blood cell transfusion within 30 days prior to the date of the CBC reported in question 23.

Section Updates:

Question Number	Date of Change	Add/Remove/Modify	Description	Reasoning (If applicable)
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