LABORATORY RESULT FORM

Name: Date Requested:

Age: Patient Number:
Gender: Date of Birth:
Method: DOH Accredited Lic. No.:

Chemical Examination Physical Examination

Glucose Nitrite Color
Bilirubin Protein Clarity
Ketone Leukocytes Specific Gravity
Urobilinogen Blood pH
Microscopic Examination
Parameter Result Reference Values Remarks
Yeast None
Bacteria None
RBC 0 – 4 /HPF
WBC 0 – 4 /HPF
Mucus Threads Occasional
Epithelial Cells < 15-20 / HPF
Casts 0 – 5 hyaline casts / LPF
Crystals Occasional
URINALYSIS

MILEENA NICHOLE MORALES

Lic. No. 0099182 Lic. No.
Medical Technologist Pathologist