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 ___________________________