ICVC Charitable Trust Apollo Centre Desborough Road High Wycombe HP11 2QW

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ICVC international clinical virology centre
Resistance Request Form
PLEASE FILL IN ALL SECTIONS CLEARLY
HOSPITAL No ______________________ HOSPITAL /
CLINIC___________________________________________
____
SURNAME _________________________ CONSULTANT
/ DOCTOR_________________________________________
_
FORENAME________________________
PHONE____________________________________________
_______________
DATE OF BIRTH____________________
FAX______________________________________________
________________
SEX M F
SAMPLE DETAILS DATE_____________
TIME_____________ BASELINE URGENT
Sample viral load (date) ____________(____/____/_
___) Most recent CD4__________
Origin of Infection Europe Africa Asia
N. America S. America Australia
Other_________
Current drug therapy_____________________________
__________________________________________________
_____
Major reason for test____________________________
_________________________________________________
Adherence comment________________________________
__________________________________________________
_
Please, complete the following information to
assist us with testing and clinical reporting
Ethnic Origin White Non Hispanic Black
African Hispanic
Afro-Caribbean Asian
Middle Eastern Other _______________

Sub-continent
Oriental Date of Diagnosis
_____________ Undergoing Acute Infection Yes
No Risk Exposure Group Heterosexual
contact Men who have sex with Men (MSM)
Blood/ Tissue Transfer Intravenous Drug User
(IDU) Mother to Child MSM/ IDU
Other______________
For Lab Use only Date____________
RV Number___________
Q18 Issue 2 Page 1 of 1
ICVC Charitable Trust - Apollo Centre -
Desborough Road High Wycombe - HP11 2QW Tel
(44) 01494 836 503 - Fax [phone]