DEPARTMENT OF HEALTH

RESEARCH INSTITUTE FOR TROPICAL MEDICINE Document Control No.:

Alabang, Muntinlupa City, Metro Manila LRD-DIV-SPE-FM-001a
(02) 8072628 to 32
www.ritm.gov.ph

Hospital No.: LABORATORY TEST REQUEST FORM Accession No.:

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I. PATIENT INFORMATION: (to be filled-up by requisitioner)
Name: (First, Middle, Last) Date of Birth:
(MM/DD/YYYY)
Address: (Street, Barangay. District, Municipality, Province, Region) Sex: ☐M Age:
WWW.RITM.GOV.PH ☐F (YY.MM)
Clinical Impression: Location/ ☐ OPD ☐ Referral Date of Admission:
Classification: ☐ AS ☐ RITM INPATIENT _____ (MM/DD/YYYY)
Suspected Agent: Date of Onset of Illness:
(MM/DD/YYYY)
II. REQUISITIONER INFORMATION: (to be filled-up by requisitioner)
Requisitioner (MD)/Disease Surveillance Officer Name: Address: Requisitioner (MD)/DRU Contact Details: (at least 1)
Tel No.: ____________________________________
Fax No.:____________________________________
Name of Disease Type of DRU: Region: Province: Municipality: Cell No.: ____________________________________
Reporting Unit (DRU): Email Address: ______________________________
III. SPECIMEN INFORMATION: (to be filled-up by requisitioner for pre-collected specimens or RITM staff)
Specimen Type: ☐ Blood ☐ Cerebrospinal Fluid ☐ Sputum ☐ Urine ☐ Stool Date and Time of Specimen Collection:
☐ Tissue ☐ Nasopharyngeal Swab ☐ Abscess Aspirate ☐ Others ________________________ (MM/DD/YYYY HR:MIN)
Collected by:
Anatomic Site of Origin (if appropriate): _______________________________________________________ printed name & signature
IV. HOSPITAL INFORMATION: (to be filled-up by RITM staff)
Laboratory Number: Official Receipt No.: Specimen Acceptable:
☐ YES
Date and Time of Specimen Receipt: Received by: ☐ NO (reason) ________________________
(MM/DD/YYYY- HR:MIN) printed name & signature
V. LABORATORY TESTS: (to be filled-up by requisitioner- please mark with an “x” box of the requested examination) ☐STAT Request
CLINICAL LABORATORY
HEMATOLOGY Smear PULMONARY LIPID PROFILE LIVER FUNCTION TEST BODY FLUID CHEMISTRIES
☐ Complete blood count ☐ Coagulation Time ☐ Arterial Blood Gas (ABG) ☐ Cholesterol ☐ Albumin (A) ☐ CSF Glucose
w/ platelet ☐ Prothrombin Time ☐ HDL ☐ Alkaline Phosphatase ☐ CSF Protein
☐ Hemoglobin & ☐ Partial Thromboplastin GLUCOSE ☐ LDL ☐ Total Protein (TP) ☐ 24 hour Urine
Hematocrit Time ☐ Fasting Blood Sugar ☐ Triglyceride ☐ Globulin (G) Creatinine
☐ Reticulocyte count BLOOD BANK ☐Oral Glucose Tolerance ☐ TPA/G ☐ 24 hour Urine Protine
☐ Erythrocyte ☐ Blood Typing Test ELECTROLYTES ☐ A/G Ratio ☐ Creatinine Clearance
Sedimentation Rate ☐ Coomb's Test (Direct) ☐ Random Blood Sugar ☐ Sodium ☐ Bilirubin, Direct
☐ Clot Retraction Time ☐ Coomb's Test (Indirect) ☐ Glucose 1 hr Challenge ☐ Potassium ☐ Bilirubin, Indirect OTHER CHEMISTRIES
☐ Clotting Time ☐ Cross-matching Test ☐ Calcium ☐ Bilirubin, Total ☐ Amylase
☐ Bleeding Time ☐ HbA1C ☐ Chloride ☐ Bilirubin (Total,Direct, ☐ CPK
☐ Lupus Erythematosus CLINICAL MICROSCOPY ☐ Inorganic indirect) ☐ LDH
(LE) Preparation ☐ Urinalysis POSTPRANDIAL BLOOD Phosphorus ☐ SGOT/AST ☐ Uric Acid
☐ Peripheral Blood ☐ Cell count/differential SUGAR (PPBS) ☐ Magnesium ☐ SGPT/ALT
☐ 1 hr PPBS
☐ 2 hr PPBS RENAL FUNCTION TEST
☐ 3 hr PPBS ☐ BUN
☐ Creatinine

☐ OTHERS
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