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. MFM-Glucose Challenge, 1 Hour   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for MFM-Glucose Challenge, 1 Hour
CPT Code: 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. Patients should eat their usual diet for 3-5 days and fast 8 hours prior to testing. Glucose dose will be orally administered and blood will be collected at the 1 hour interval post glucose ingestion.

TAT: 1 hour/draw


Lab/Phone: 330-746-9623

Additional Info: Criteria for Diagnosis of Gestational Diabetes Mellitus(GDM) Effective 6/22/2011 50g, 1HR Glucose Challenge >130 mg/dl Detects 90% of those who will develop GDM >140 mg/dl Detects 80% of those who will develop GDM

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: