PLATELET ALLOIMMUNIZATION REQUEST

Name: Date:

CPI #: Age:

Primary Diagnosis: Sex: (M/F)

Recent History (Brief)

PAST MEDICAL HISTORY (Y/N):

Pregnancies (#): Hx ITP/PTP:

Transplant/date: Other Autoimmune:

Past surgeries/date:

PATIENT FACTORS (Circle/note):

Splenomegaly size= Body Mass* BSA/kg=

Fever Tmax= Infection Cultures:

Neutropenic WBC=

ANC= CXR:

Renal Failure BUN/Cr= (other)

Bleeding Site Hemolysis LDH

DIC PT/PTT DAT

D-dimer Smear

Fibrinogen Other:

*Body surface area (M2), Kg body weight

MEDICATIONS (circle/note)

Heparin ATGAM/ALT/ATG Amphotericin Other

Ticlopidine IVIgG Fluconazole

Clodipregel WinRo/Rhogam Vancomycin

Quinidine Ciprofloxacin

Revision 6/28/01 T59

BLOOD BANK LABORATORY STUDIES:

RBC SEROLOGY: PLATELET CROSSMATCH:

ABO Type: (Dates/Results)

RBC Ab Screen:

TISSUE TYPE/ANTI-HLA ANTIBODIES: Call HLA Lab

HLA Type: PRA (%/Date)

HLA specificitie(s)

PLATELET TRANSFUSION HISTORY

R/SD Platelet Count

Date Unit # ABO CXM/HLA Pre Post CCI