Document y2n0RJegL1Nno96EQGy2x68D
CLEARING INDUSTRIAL CLINIC
STATE RES. NO 928
Clinical Laboratory
5548 WEST SIXTY-FIFTH STREET CHICAGO. ILLINOIS 60638
PHONE 787-0800
4/3/________ 3/
NAME
URINALYSIS:
SPECIFIC GRAVITY REACTION ___________
COLOR _______________ SUGAR _______________ ALBUMIN
ACETONE OCCULT BLOOO -
PREGNANCY TEST:
HEMATOLOGY: HEMOGLOBIN ___ HEMATOCRIT ____
DIFFERENTIAL COUNT: NEUTROPHIL* BASOPHILS -- MONOCYTES --
CELL MORPHOLOGY
BLOOD TYPE__________________ OTHER SEDIMENTATION RATE:
BLOOD CHEMISTRY:
SUGAR FASTING
..
CHOLESTEROL UR'C ACID SMEARS:
___
w-----------
(Mat Oi/t/iA
LABORATORY REPORT
MICRO: W. B. C. R. B. C. CASTS _ CRYSTALS EPITH. CELLS OTHERS _______
CONFIDENTIAL INFORMATION
REDACTED
PLATELET COUNT
LYMPHOCYTES EOSINOPHILS . OTHERS ________
MM IN 80 MINUTES
. Ma/lOO ee BLOOO . M/100CC BLOOD
2 HR. P.P. BUN _______ OTHER
Ma/too ee BLOOD .Ma/lOO cc BLOOD
SEROLOGY: MONO TEST
CYWT 3-001179
N14517
CLEARING INDUSTRIAL CLINIC
STATE REOr-NO 328
Clinical Laboratory
5548 WEST SIXTY-FtFTH STREET CHICAGO. ILLINOIS 60638
PHONE 767-6600
5-3/
..<</
NAME
URINALYSIS:
SPECIFIC GRAVITY
REACTION
___________ _
COLOR SUGAR ALBUMIN
L A
ACETONE
JOCCULT BLOOD O-
LABORATORY REPORT
MICRO: W. B. c. R. B. c. CASTS _
^z3
0 o
CRYSTALS EPITH. CELLS
as
OTHERS
CONFIDENTIAL INFORMATION
REDACTED
PREGNANCY TEST
HEMATOLOGY HEMOGLOBIN HEMATOCRIT
^V7
PLATELET COUNT
DIFFERENTIAL COUNT:
*S3.NEUTROPHILS
BASOPHILS _
-ex
MONOCYTES _ CELL MORPHOLOGY _________
-A
BLOOD TYPE__________________
LYMPHOCYTES
EOSINOPHILS
OTHERS ^%4/fc/ 51
BLOOD CHEMISTRY:
SMEARS:
SEROLOGY: MONO TEST RA LATEX _
LEAD ANALYSIS OF URINE:
LEAD ANALYSIS OF BLOOD:
----------- ROBERT E.-BOY-Qt Mt Q.
\ 5548 W. 65th ST. _____________ CHICAGO, TIL 60638
MEDICAL DIRECTOR
CYWI 3-001180
CLEARING INDUSTRIAL CLINiC
EMPLOYMENT HEALTH QUESTIONNAIRE
NAME:
_________________ DATE:
COMPA^Y: jsnffiS)JSl4Wr)
AGE: S/d HEIGHT: ^ ^ WEIGHT: /fe-?*)
HISTORY OK PREfcVvIOioUuSs LUNG DISEASES AND YEAR:
PNEUMONIA A)d
ASTHMA:
/ffl
CHRONIC BRONCHITIS: 7M-
ALLERGIES: Aid
_E MPUYS EV&i Ain TUBERCULOSIS: Ah
jJLPNEUMOCONIOSES (Silicosis, Asbestosie, Coal-Miners Diseaslee, Etc.):
HISTORY OF HEART DISEASE:
SMOKING HISTORY:
DO YOU SMOKE CIGARETTES NOW?
YES
NO
IF YES, HOW MANY PER DAY?______
WHEN DID YOU START (AGE)?
IF NO, DID YOU EVER SMOKE CIGARETTES? YES
NO
IF YES, WHEN DID YOU START (AGE)?___ WHEN DID YOU STOP (AGE)?
HOW MANY PER DAY?
IX) YOU SMOKE CIGARS? DO YOU SMOKE A PIPE?
YES. YES*
NO NO"
DO YOU HAVE ANY OF THE FOLLOWING SYMPTOMS: IF YES, EXPLAIN.
SHORTNESS OF BKEATH^DSYPNKA); N6
AFTER EXERTION:
NoCOUGH:____
DHY: No
EXPECTORATION:
1H.OOD SPITTING:, Mq .
71PAIN OH DISCOMFORT IN EST:
T&
IOSS OF APPETITE
loss OF WEIGHT:
/[/ft
HAVE YOU EVER WORKED:
AS A HARD ROCK MINER?
YES
WITH ASBESTOS?
yes"
WITH DIATOMACEOUS EARTH? y e s "
AS A COAL_MS&|!t? / '
yes"
IN A JOB THATTREQUIRED AN
X-RAY FILM BfpGE? AS A WELDER?-- IN A TEXTIUTMIIX?
YES, yes] yes"
wrni TALC?
yes"
IN ANY OTHER DUSTY JOB?
yes"
WITH EXPOSURE TO EXCESSIVE
NOISE ?
NO j/ FROM NO,X f r o m"
"n o //"f r o m"
"n o z/f r o m"
NO tX FROM NO FROM" NO FROM NO FROM NO ^ /"FROM
NO ^FROM
TO TO] "t o ] "t o
TO.
TO]
"t o ] _t o _ "t o "
TO
SIGNED
INTERVIEWER
CONFIDENTIAL INFORMATION
r edac t ed
1HOYEE
C^1 3-00U81
CENTRAL LABORATORY FACILITY
i L. sc i >X':
* ; v : a -3CC02:
C0728NQT GIVEN
09/01/84
; ;JCNc?~ c SfllEh. M a08ER* a 0CR3C. M 0
*C i
OSNSil. -<RO*K Oi
09/02/84
CLEARING INDUSTRIAL CL1NI
31851
3ND
AMERCYAN
5548 W. 65TH
CHICAGO
IL
60633
170247
TEST NAME
RESULT
UNITS REFERENCE RANGE
******************************************************************************
TEST RESULTS OUTSIDE ESTABLISHED REFERENCE RANGE
CREATININE,SERUM
1.50
MG/OL
BUN,SERUM
31.0
MG/OL
.80-1.|0 9.00-231
SXm
CYWI 3-00X182
Code i Cooe 2. Code 3 Coc^. -. Code 5: Code 6: Code 7Code 8: Code 9: Code 10: Code 11: Code 12: Code 13:
Code 15.
tf whole h.occ s -ece'ved sy th = -ac cr -re pe; Darner >s defective for any reason, faise eievat.on cf u Gh d c :2s s Phosonate as we as a`a-se zec-e.-.:. - 3 -jcose may oe seen
i.-o- a~z
3ac:ena> contamination or ce-ayec separation of serum from cells may faiseiy decrease Guccse anc may `a.se'y eievate the Potassium. LDm pnospnate SGOT a no 5GPT
Sedimentation Rate results na, oe affectec if me time Detween specimen drawing ana testing .s prolonged R;ease note me cate orawn a.no cate received
Piate'et results may De affected .1 tne time oetwee.n specimen drawing and testing is prolonged Please note me cate craw- am cate received
Protnromoin Time results may oe af fee tec if tne t.me between specimen drawing and testing is prolonged. Piease -ow me cate c and date received
Activateo Partial Tnrombopiastm Tme results may be affecteo if tne time between specimen drawing and testing .3 or; ongec = ea;-:note tne date drawn ana aate receiveo
Hemolyzed serum may faiseiy elevate tne Potassium, iron, SGOT. SGPT. uDH. ana Phosphate.
Lipemic serum may falsely elevate the Cnionde. Alkaline Phosphatase, SGOT. SGPT, Calcium, Total Protein, ano Creat.n.re o-c -^. falsely lower the Totai Bilirubin.
The specimen was upemic. Such specimens are unsatisfactory for analysis on our multichannel analyzer. Manual procedures we-e substituted for those assays on which valid results could be obtained.
Plasma may adversely affect the following Cnem-Screen tests--Calcium. Alkaline Phosphatase. LDH. Sod'um Magnesium and Potassium.
One or more of the specimens submitted was not properly identified. To assure the integrity of the specimen identity, it is .mperta-r that the patient name or ID code placed on the requisition also be placed on every specimen submitted with the requisition
incorrect specimen sent. EDTA plasma is the only acceptable specimen for CEA Roche testing. Any other sample, including serum M
and other anticoagulants, may cause faiseiy elevated results.
;
incorrect specimen received. Freezing destroys the seal in the barrier tube. Upon defrosting. Hemoglobin and other ceiluiar mater *'
are released into tne serum, invalidating the specimen. Please submit another specimen by centrifuging and pouring off tne ser,,m |
into.a plastic tube, which can then be frozen.
fe,
Specimens submitted for L.E. preparations m barrier tubes are unsatisfactory for testing Please submit a plain rea-top tube containing clotted blood for L.E. tests.
?
CYWI 3-001183