NAME__________________________Date:______ Labs CD4 ð
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NAME__________________________Date:___________ NAME__________________________Date:___________ NAME__________________________Date:___________ Labs Labs Labs CD4 HIV VL HIV Genotype Dx:_ 042_____ HCV VL HCV Genotype Dx: 070.54__ CMP ___________ BMP ___________________ FLP_____________ Hepatic Function___________ Vit. D __268.9 ____ TSH_____________________ CBC w/diff________ CBC w/o diff______________ HbgA1c__________ F/T Testosterone__________ Hematocrit_______ Hemoglobin_______________ Hep panel________ Hepatitis A or B or C_______ CD4 HIV VL HIV Genotype Dx:_ 042_____ HCV VL HCV Genotype Dx: 070.54__ CMP ___________ BMP ___________________ FLP_____________ Hepatic Function___________ Vit. D __268.9 ____ TSH_____________________ CBC w/diff________ CBC w/o diff______________ HbgA1c__________ F/T Testosterone__________ Hematocrit_______ Hemoglobin_______________ Hep panel________ Hepatitis A or B or C_______ CD4 HIV VL HIV Genotype Dx:_ 042_____ HCV VL HCV Genotype Dx: 070.54__ CMP ___________ BMP ___________________ FLP_____________ Hepatic Function___________ Vit. D __268.9 ____ TSH_____________________ CBC w/diff________ CBC w/o diff______________ HbgA1c__________ F/T Testosterone__________ Hematocrit_______ Hemoglobin_______________ Hep panel________ Hepatitis A or B or C_______ Other:________________________Dx:____________ Other:________________________Dx:____________ Other:________________________Dx:____________ Screenings Screenings Colonoscopy FOB/FIT Mammogram GC/CT RPR UA TB screen Immunizations: __________________________ DM Screen Screenings Colonoscopy FOB/FIT Mammogram GC/CT RPR UA TB screen Immunizations: __________________________ DM Screen Urine Micro Foot Exam Eye Exam Colonoscopy FOB/FIT Mammogram GC/CT RPR UA TB screen Immunizations: __________________________ DM Screen Urine Micro Foot Exam Eye Exam Urine Micro Foot Exam Eye Exam Next PE due ______________ Next Labs due ___________ Next PE due ______________ Next Labs due ___________ Next PE due ______________ Next Labs due ___________ Notes:__________________________________________ ________________________________________________ ________________________________________________ Notes:__________________________________________ ________________________________________________ ________________________________________________ Notes:__________________________________________ ________________________________________________ ________________________________________________ NAME__________________________Date:___________ NAME__________________________Date:___________ NAME__________________________Date:___________ Labs Labs Labs CD4 HIV VL HIV Genotype Dx:_ 042_____ HCV VL HCV Genotype Dx: 070.54__ CMP ___________ BMP ___________________ FLP_____________ Hepatic Function___________ Vit. D __268.9 ____ TSH_____________________ CBC w/diff________ CBC w/o diff______________ HbgA1c__________ F/T Testosterone__________ Hematocrit_______ Hemoglobin_______________ Hep panel________ Hepatitis A or B or C_______ CD4 HIV VL HIV Genotype Dx:_ 042_____ HCV VL HCV Genotype Dx: 070.54__ CMP ___________ BMP ___________________ FLP_____________ Hepatic Function___________ Vit. D __268.9 ____ TSH_____________________ CBC w/diff________ CBC w/o diff______________ HbgA1c__________ F/T Testosterone__________ Hematocrit_______ Hemoglobin_______________ Hep panel________ Hepatitis A or B or C_______ CD4 HIV VL HIV Genotype Dx:_ 042_____ HCV VL HCV Genotype Dx: 070.54__ CMP ___________ BMP ___________________ FLP_____________ Hepatic Function___________ Vit. D __268.9 ____ TSH_____________________ CBC w/diff________ CBC w/o diff______________ HbgA1c__________ F/T Testosterone__________ Hematocrit_______ Hemoglobin_______________ Hep panel________ Hepatitis A or B or C_______ Other:________________________Dx:____________ Other:________________________Dx:____________ Other:________________________Dx:____________ Screenings Screenings Colonoscopy FOB/FIT Mammogram GC/CT RPR UA TB Screen Immunizations: __________________________ DM Screen Screenings Colonoscopy FOB/FIT Mammogram GC/CT RPR UA TB Screen Immunizations: __________________________ DM Screen Urine Micro Foot Exam Eye Exam Colonoscopy FOB/FIT Mammogram GC/CT RPR UA TB Screen Immunizations: __________________________ DM Screen Urine Micro Foot Exam Eye Exam Urine Micro Foot Exam Eye Exam Next PE due ______________ Next Labs due ___________ Next PE due ______________ Next Labs due ___________ Next PE due ______________ Next Labs due ___________ Notes:__________________________________________ ________________________________________________ ________________________________________________ Notes:__________________________________________ ________________________________________________ ________________________________________________ Notes:__________________________________________ ________________________________________________ ________________________________________________
