Fat, Feces (Qualitative and Quantitative)
| PATIENT INFO |
| Patient Name: |
| Medical Record #: |
| BD: / / Sex: F M |
| PHYSICIAN INFO |
| Physician Name : |
| Address: |
| Ph: ( ) - Fax: ( ) - |
| Additional Report to: |
| Ph: ( ) - Fax: ( ) - |
| TESTS REQUESTED | |
| Test Name: | ICD9 Code: (required) |
| 1. Fat, Feces (Qualitative and Quantitative) | |
| 2. | |
| 3. | |
| 4. | |
| 5. | |
| 6. | |
| SPECIMEN INFO |
| Collection Date & Time: |
| Collected By: |
| Hospital: |
Test ID :
FATF
Test Workstation :
MAYO
Specimen Type:
Stool
Tube Type:
Stool container
Collection Volume:
Qualitative: min 5 grams. Quantitative: Entire 24, 48 or 72 hour stool collection (send all stool); entire collection must contain at least 5 grams.
Storage:
Frozen
Availability:
Sent to reference lab
Methodology:
Nuclear Magnetic Resonance (NMR) Spectroscopy
Special Instructions:
For Qualitative requests, please indicate that stool is a RANDOM collection.
For Quantitative requests (24, 48 or 72 hour stool), mark each container with patient information and date and time collection started and finished, and number of containers (ex., 1 of 4).
For 3 days prior to and during the collection period:
no barium, no laxatives, no synthetic fat substitutes or fatblocking nutritional supplements. The use of diaper rash ointments will falsely elevate test results.
Lab/Phone:
330-543-8418
TAT:
1-3 days
Additional Info:
Ref. range:
> or = 18 years: 2-7 g/24 hrs
Reference values have not been established for patients who are <18 years of age
Random Collection: All ages: 0-19% fat
CPT Code:
82710
Synonyms:
Fecal Fat, Qualitative
Fecal Fat, Quantitative
