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Head Office |
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Light House Hill Road, Mangalore - 575001; Tel: (91-824) 2443636, 2423680, 5267636 |
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Specialties Division |
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B4, City Plaza Complex, Kudmul Ranga Rao Road, Mangalore - 575003; Tel: 2497636, 5277636 |
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Branch |
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ABEB Complex, Opp. Juma Masjid, Main Road, Bajpe - 574142. Tel: (91-824) 2253475 |
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Nova Meditech Metabolic Diseases Laboratory
Requisition for Metabolic Diseases Screening Test
Please fill this form with all the available data and kindly send it along with the specimen. Information on drugs being administered is especially important as some drugs may interfere with test results. Diet related symptoms, if any, may kindly be mentioned.
| Name: | Age: | Sex: |
| Address: | ||
| Mother's Name: | Father's Name: | |
| Siblings: | Patient's order: | Anyone previously affected: |
| Blood Group of mother: | Blood Group of father: | |
| Consultant's name: | Consultant's telephone no: | Hospital: |
| Unexplained/sudden infant deaths in previous siblings: | ||
| Drug treatment being given: | ||
| History of diet and diet related symptoms (e.g. Diarrhoea related to milk etc.): | ||
| Indication for screening: Emergency/Non-emergency | ||
| 1. Routine for new born | 2. Brought by parents/self | 3. Other |
| Symptoms/Signs: (Select appropriate) | ||
| Poor feeding | Critically ill neonate | Failure to thrive |
| Sepsis | Vomiting | Diarrhoea |
| Tachypnea/apnea | Bradycardia | Temperature instability |
| Irritability | Seizures | Altered sensorium |
| Lethargy | Coma | Involuntary movements/ posturing |
| Abnormal muscle tone | Hallucinations/delirium | Aggressiveness/agitation |
| Psychiatric problems | Autism | Behavioural disturbances |
| Skeletal abnormalities | Abnormalities of skin/hair | Dysmorphic/coarse facial features |
| Delayed milestones | Learning disorders | Ataxia |
| Premature cataracts | Organomegaly: | |
| Jaundice/liver dysfunction | Hepatoencephalopathy | Abnormal odour |
| Exercise intolerance | Muscle weakness | Paraparesis |
| Abdominal pain | Migraine-like head aches | Any other |
| Specimen: | Urine (20 cc) | Plasma (2 cc) | Serum (2 cc) | Whole blood (5 ml) | CSF (2 cc) |
| Collection Time: |
Instructions for collecting specimens:
Urine:
Preferably send 24 hour urine frozen till transport. Alternatively, 3 early morning urine samples, 20 ml each could be collected. The samples should be frozen immediately after collection and should be sent to Nova Laboratory within 6 hours. Spot urine samples can be collected afresh at Nova or can be refrigerated and sent as above. One additional sample must be collected between 9 am and 6 pm on the first day.Blood: Whole blood in 4% EDTA or Heparin (0.2 ml heparin for 5 ml blood), refrigerated immediately (not frozen) after collection should be sent to Nova Laboratory at the earliest. Specimen collected with any other anticoagulant is unsuitable.
Please note:
Contaminated samples, wrongly frozen samples and clotted samples will be rejected.
Please ensure that the prescribed volumes of the specimen are sent.
Kindly mention the name and collection time on every specimen bottle clearly.
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