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Prolog

This document is a laboratory request form from Mecharie Medium Clinic. It lists various hematology, chemistry, serology, hormone, and other tests that can be requested along with their normal reference ranges. The form collects information like the patient's name, age, sex, medical record number, diagnosis, and sample details. The requesting doctor and reporting lab technician would document their details as well. The form serves to order specific lab tests and document the results for a given patient.

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Roha Cbc
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
25 views

Prolog

This document is a laboratory request form from Mecharie Medium Clinic. It lists various hematology, chemistry, serology, hormone, and other tests that can be requested along with their normal reference ranges. The form collects information like the patient's name, age, sex, medical record number, diagnosis, and sample details. The requesting doctor and reporting lab technician would document their details as well. The form serves to order specific lab tests and document the results for a given patient.

Uploaded by

Roha Cbc
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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መቻሬ መካከለኛ ክሊኒክ MECHARIE MEDIUM CLINIC

የላብራቶሪ መጠየቂያ ቅጽ LABORATORY REQUEST FORM

Name: _____________________________________ Age: ____ Sex:___ MRN:______________ Date:______________ Dx: __________________________

HEMATOLOGY URINALYSIS CHEMISTRY RESULT Ref. Value SEROLOGY HORMONE


CBC Chemical RBS/FBS 70-126 mg/dl HCG/Preg/ test Free T3
Hgb/Hct  Ph SGOT/AST To 40 U/L Coomb’s test /D/ Free T4
ESR  SG SGPT/ALT To 40 U/L Coomb’s test /I/ TSH
Blood group/Rh  Protein Alk. Phosph To 270 U/L HCV Prolactine
PTT  Ketone T. Bilirubin To 1.2 mg/dl HBsAg LH
PT & INR  Sugar D. Bilirubin To 0.2 mg/dl ST FSH
Blood film  Leukocyte I. Bilirubin 0.2-1.0 mg/dl Salmonella Typhi O HbA1C
Blood morphology  Nitrite Creatinine 0.7-1.2 mg/dl Salmonella Typhi H PSA
PARASTOLOGY  Bilirubin Urea/BUN 15-40 mg/dl Proteus OX19 Estradiol
Stool exam  Blood Albumin 3.5-5.5 g/dl RF CK-MB
MICROSCOPY Total protein 6.6-8.7 mg/dl ASO C. Troponin
Occult blood  RBC Triglyceride <150 mg/dl VDRL/RPR Others
ELECTROLYTE  WBC T. cholesterol <200 mg/dl H.Pyelori serum Ab
 Na  Epithelial cells LDL <100 mg/dl HIV(PIHCT)
 K  Casts HDL 35-55 mg/dl
 Ca Others Uric acid 3.5-7.2 mg/dl H.Pyelori stool Ag
 Cl Urine HCG LDH Bacteriology Fluid analysis
OTHERS Gram stain AFB 1
Indian ink KOH
Semen analysis Wet/dry
mount
Sample____________________________ Time of sample collection _______________ Time of reporting_____________________

Requested by _____________________________ Reported by ______________________________ Report Date ___________________________

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