Hemolytic Anemia Evaluation Form
Please complete this form to assist in the evaluation of hemolytic anemia. Provide as much detail as possible for accurate assessment.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
*
Male
Female
Other
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Symptoms (Select all that apply)
*
Fatigue/Weakness
Jaundice (yellowing of skin/eyes)
Dark urine
Pale skin
Shortness of breath
Rapid heartbeat
No symptoms
Other
Duration of Symptoms (in days)
Relevant Medical History
Autoimmune disease
Recent infection
Recent medication use
Recent blood transfusion
Recent travel
No relevant history
Other
Family History of Anemia or Blood Disorders?
Yes
No
Unknown
Recent Laboratory Findings
*
Rows
Normal
Abnormal
Not Available
Hemoglobin
1
2
3
Reticulocyte count
4
5
6
Bilirubin
7
8
9
LDH (Lactate Dehydrogenase)
10
11
12
Haptoglobin
13
14
15
Additional Comments or Relevant Information
Assessment of Severity (1 = Mild, 5 = Severe)
Mild
1
2
3
4
Severe
5
1 is Mild, 5 is Severe
Submit Evaluation
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