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. Glucose, 2HR Challenge   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Glucose, 2HR Challenge
CPT Code: 82947, 82950

Specimen Type: Blood

Tube Type/Collection Container: Green top (lithium 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 orally administered and blood will be collected at the 2 hour interval post glucose ingestion.

TAT: 1 hour/draw


Lab/Phone: 330-543-8417

Additional Info: Criteria for Diagnosis of Diabetes(2HR Challenge): Fasting specimen (no caloric intake for at least 8 hours). <100 mg/dl Normal 100-125 mg/dl Increased Risk for Diabetes >125 mg/dl Diagnostic for Diabetes 2 Hour Specimen (post glucose administration). <=139 mg/dl Normal 140-199 mg/dl Increased Risk for Diabetes >=200 mg/dl Diagnostic for Diabetes

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: