Date blood drawn __________
Enter the date of blood draw. Enter the date in the DD/MMM/YYYY format.
Hemoglobin A1C _______ %
Enter the A1C value in the “NNNN.N” format. This format allows for up to four digits prior to the decimal and up to one digit after the decimal.
A1C result out of range ☐
If A1C was out of range, mark this check box.
A1C not done ☐
If A1C was not done, leave previous fields blank and mark this check box.
Was this an annual test or for cause
Indicate the reason this test was performed.
- Annual Test
- For cause
Cholesterol _______ mg/dL
Enter the cholesterol value in the “NNNNN” format. This format allows for up to five digits prior to the decimal and no digits after the decimal.
Cholesterol result out of range ☐
If cholesterol was out of range, mark this check box.
Cholesterol not done ☐
If cholesterol was not done, leave previous fields blank and mark this check box.
Was this an annual test or for cause
Indicate the reason this test was performed.
- Annual
- For cause
HDL _______ mg/dL
Enter the HDL value in the “NNNNN” format. This format allows for up to five digits prior to the decimal and no digits after the decimal.
HDL result out of range ☐
If HDL was out of range, mark this check box.
HDL not done ☐
If HDL was not done, leave previous fields blank and mark this check box.
Was this an annual test or for cause
Indicate the reason this test was performed.
- Annual Test
- For cause
LDL _______ mg/dL
Enter the LDL value in the “NNNNN” format. This format allows for up to five digits prior to the decimal and no digits after the decimal.
LDL result out of range ☐
If LDL was out of range, mark this check box.
LDL not done ☐
If LDL was not done, leave previous fields blank and mark this check box.
Was this an annual test or for cause
Indicate the reason this test was performed.
- Annual Test
- For cause
Triglycerides _______ mg/dL
Enter the triglycerides value in the “NNNNN” format. This format allows for up to five digits prior to the decimal and no digits after the decimal.
Triglycerides result out of range ☐
If Triglycerides was out of range, mark this check box.
Triglycerides not done ☐
If Triglycerides was not done, leave previous fields blank and mark this check box.
Was this an annual test or for cause
Indicate the reason this test was performed.
- Annual Test
- For cause
CCG v.1 | CRF v.1
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