| immu_date |
|
text |
Date |
|
| auto_imm_done |
Auto-immune Screen |
checkbox |
Please tick all tests that have been DONE |
1, Antinuclear antibody (ANA) titre ; 2, Anti-glomerular basement membrane antibody (Anti-GBM) titre ; 3, ENA screen ; 4, ANCA screen ; 5, MPO-ANCA antibody level ; 6, PR3-ANCA antibody level ; 7, dsDNA ; 8, Anticardiolipin (aCL) antibodies ; 9, Anti-β2-Glycoprotein I (Anti-β2GPI) antibodies ; 10, Lupus anticoagulant antibodies ; 11, Anti-CCP ; 12, Rheumatoid Factor (RF) |
| ana |
|
text |
Antinuclear antibody (ANA) titre |
|
| agbm |
|
text |
Anti-glomerular basement membrane antibody; (Anti-GBM) titre |
|
| ena |
|
radio |
ENA screen |
1, Positive ; 0, Negative |
| anca |
|
radio |
ANCA screen |
1, Positive ; 0, Negative |
| ena_detail |
|
text |
ENA screen - Predominant proteins (anti - Ro/SS-A, La/SS-B, Sm, RNP, Scl-70 and Jo1) |
|
| manca_less_greater |
|
dropdown |
MPO-ANCA antibody level - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| manca |
|
text |
MPO-ANCA antibody level - Result (IU/ml) |
|
| manca_other_unit |
|
text |
MPO-ANCA antibody level - If using a different unit other than IU/ml |
|
| panca_less_greater |
|
dropdown |
PR3-ANCA antibody level - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| panca |
|
text |
PR3-ANCA antibody level -Result (IU/ml) |
|
| panca_other_unit |
|
text |
PR3-ANCA antibody level - If using a different unit other than IU/ml |
|
| dsdna_less_greater |
|
dropdown |
dsDNA - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| dsdna |
|
text |
dsDNA |
|
| dsdna_other_unit |
|
text |
dsDNA - If using a different unit |
|
| acl_less_greater |
|
dropdown |
Anticardiolipin (aCL) antibodies - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| acl |
|
text |
Anticardiolipin (aCL) antibodies |
|
| acl_other_unit |
|
text |
Anticardiolipin (aCL) antibodies - If using a different unit |
|
| ab2gpi_less_greater |
|
dropdown |
Anti-β2-Glycoprotein I (Anti-β2GPI) antibodies - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| ab2gpi |
|
text |
Anti-β2-Glycoprotein I (Anti-β2GPI) antibodies - Result |
|
| ab2gpi_other_unit |
|
text |
Anti-β2-Glycoprotein I (Anti-β2GPI) antibodies - If using a different unit |
|
| lag_less_greater |
|
dropdown |
Lupus anticoagulant antibodies - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| lag |
|
text |
Lupus anticoagulant antibodies - Result |
|
| lag_other_unit |
|
text |
Lupus anticoagulant antibodies - If using a different unit |
|
| accp_less_greater |
|
dropdown |
Anti-CCP - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| accp |
|
text |
Anti-CCP - Result (u/ml) |
|
| accp_other_unit |
|
text |
Anti-CCP - If using a different unit other than u/ml |
|
| rf_less_greater |
|
dropdown |
Rheumatoid Factor (RF) - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| rf |
|
text |
Rheumatoid Factor (RF) Result (u/ml) |
|
| rf_other_unit |
|
text |
Rheumatoid Factor (RF) - If using a different unit other than u/ml |
|
| imm_done |
Immunological Screen |
checkbox |
Please tick all tests that have been DONE |
1, C3 ; 2, C4 ; 3, IgA ; 4, IgM ; 5, IgG |
| c3_less_greater |
|
dropdown |
C3 - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| c3 |
|
text |
C3 -Result |
|
| c3_other_unit |
|
text |
C3 - If using a different unit |
|
| c4_less_greater |
|
dropdown |
C4 - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| c4 |
|
text |
C4 - Result |
|
| c4_other_unit |
|
text |
C4 - If using a different unit |
|
| iga_less_greater |
|
dropdown |
IgA - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| iga |
|
text |
IgA - Result (g/L) |
|
| iga_other_unit |
|
text |
IgA - If using a different unit other than g/L |
|
| igm_less_greater |
|
dropdown |
IgM - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| igm |
|
text |
IgM - Result (g/L) |
|
| igm_other_unit |
|
text |
IgM - If using a different unit other than g/L |
|
| igg_less_greater |
|
dropdown |
IgG - Select if test result provided is not an exact value |
1, < (Less than) ; 2, > (Greater than) |
| igg |
|
text |
IgG - Result (g/L) |
|
| igg_other_unit |
|
text |
IgG - If using a different unit other than g/L |
|
| blood_virus_done |
Blood borne viruses screen |
checkbox |
Please tick all tests that have been DONE |
1, HIV ; 2, Hepatitis B ; 3, Hepatitis C |
| hiv |
|
radio |
HIV |
1, Positive ; 0, Negtive |
| hepb |
|
radio |
Hepatitis B |
1, Positive ; 0, Negtive |
| hepc |
|
radio |
Hepatitis C |
1, Positive ; 0, Negtive |