Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


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. Gestational 3HR Challenge   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Gestational 3HR Challenge
CPT Code: 82947,82951

Specimen Type: Blood

Tube Type/Collection Container: Green top ( lithium heparin or sodium heparin)tube

Collection Volume: 0.4 mL

Storage: Refrigerated

Availability: Mon-Fri

Methodology: Timed endpoint reaction using hexokinase

Special Instructions: Outpatients must be scheduled in advance. Patient should eat their usual diet for 3-5 days and fast 8 hours prior to testing. A fasting level will be drawn and must be < 125 mg/dL (glucometer) before proceeding. Glucose dose will be administered and blood will be collected at 1 hour, 2 hour, and 3 hour intervals post glucose ingestion.

TAT: 1 hour/draw


Lab/Phone: 330-543-8417

Additional Info: Criteria for Diagnosis of Gestational Diabetes Mellitus(GDM) 100g, 3HR Glucose Challenge The Diagnosis of GDM is made when two or more of the following plasma glucose values are exceeded: Fasting >=95 mg/dl 1HR Glucose >=180 mg/dl 2HR Glucose >=155 mg/dl 3HR Glucose >=140 mg/dl

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: