The Center is supported by the CDC and sponsored by the American Association of Neuropathologists.

Test Request Form


Please provide the following information for all samples submitted to the NPDPSC. Please note that it is very important that you complete the entire form to aid the NPDPSC in providing an accurate diagnosis.

1. DRAWING/SENDING LABORATORY
Your Name:
Phone: / / Fax: / /
Laboratory/Hospital:
Street Address:
City: Zip Code:


2. SAMPLES ENCLOSED. (Please check all that apply.)
CSF (Please note that we request urine be sent with all CSF samples, if available.)
Urine (Urine will only be stored for future research purposes.)
Fixed brain biopsy tissue > Treated in % formic acid for days.
Frozen brain biopsy tissue > Stored at 70º C (recommended) 20ºC Refrigerator 4ºC
Fixed brain autopsy tissue > Treated in % formic acid for days.
Frozen brain autopsy tissue > Stored at 70º C (recommended) 20ºC Refrigerator 4ºC
Blood (Please see our blood protocol for special instructions before sending blood.)


3. IS ADDITIONAL TISSUE AVAILABLE ON THIS PATIENT?
No

Yes - Please describe.


4. IN ORDER FOR THE NPDPSC TO CONDUCT GENETIC TESTING ON TISSUE OR BLOOD SAMPLES,
THE PATIENT MUST SIGN A GENETIC CONSENT FORM. HAS THE PATIENT SIGNED A GENETIC CONSENT?
Yes

No

Not applicable, no tissue or blood sent


5. TO WHOM SHOULD TEST RESULTS BE SUBMITTED? (Please check all that apply.)
Drawing Laboratory
Referring Physician


6. REFERRING PHYSICIAN
Your Name:
Phone: / / Fax: / /
Hospital/Institution:
Street Address:
City: Zip Code:


7. FOR ALL TISSUE AND BLOOD SAMPLES SENT TO THE NPDPSC, WE REQUEST THAT A FULL CLINICAL HISTORY BE SUBMITTED TO AID US IN MAKING OUR DIAGNOSIS. HAS A CLINICAL HISTORY BEEN SUBMITTED?
Yes, it is enclosed in this package
Yes, it has been submitted previously
No, it will be sent under separate cover
No history required, no tissue or blood sent


8. PATIENT INFORMATION
Name: ID#
Date of birth: / / (MM//DD/YY)
Male Female
Race:
Onset: / (MM//YY) Date of death (if applicable): / / (MM//DD/YY)
Residence of patient City:
City and state of death (if applicable) City:


9. DOES THE PATIENT HAVE ANY MILITARY EXPERIENCE?
Yes
No


10. DOES THE PATIENT HAVE A HISTORY OF ANY OF THE FOLLOWING?
Herpes encephalitis Cerebral infarction
Other viral encephalitis Acute brain trauma
None of the above


11. DOES THE PATIENT HAVE ANY FAMILY HISTORY OF CJD OR EARLY ONSET DEMENTIA?
Yes, CJD No
Yes, early onset dementia


12. DOES THE PATIENT HAVE A KNOWN HISTORY OF FOREIGN TRAVEL OR EATING WILD GAME?
Yes, foreign travel. Where?
Yes, patient at wild game or was a hunter
No, patient did not engage in either of these activities