As part of our follow-up of the children on the ketogenic diet, you must obtain the following laboratory tests one (1) week prior to clinic visits. Please fill in your child’s name and the date and have the neurologist fill in the rest.
Patient Name: ________________________________Dx. Code: 345.01
Date: _________________ Service or Clinic: Pediatric Epilepsy Center
Urinalysis
CBC with differential
Selenium level
Carnitine profile (total and free)
1,25-OH-Vitamin D level
(CMP-SMA20): to include chem panel-BUN, albumin
AST, creatinine, calcium, T. Bili, ALT, glucose, phosphorus, direct bilirubin, total protein, uric Acid, alkaline phosphatase
Complete Lipid Profile (fasting)
Anticonvulsant levels for these drugs: _________________________
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Physician’s Signature: ___________________ DEA # ______________
Physician’s Name (print): _____________________________________
PLEASE FAX RESULTS TO:____________________________