Kelle Primary Hospital Laboratory Request

Patient Name___________________________________ Age__________ Sex _____ MRN_____________

Woreda_____________________ Kebele_______________ Department _____________________

Requested by_________________________Signiture__________ Date & Time_____________________

CBC Hgb RFT

WBC MCH Creatinine
Lym % MCHC BUN (Urea)
Mid % RBC LFT

Clinical Chemistry
Gra % MCV SGOT(AST)
Hematology

Lym HCT SGPT(ALT)

Mid PLT AlkP
Gra Serum Glucose
ESR Bilirubin-(Total)
-(Direct)
Peripheral Morphology
Uric acid
WBC
Diabetic Panel
RBC FBS
RBS
BG & RH Blood film for H/P
X-Match, -Major
-minor Parasitology Stool Ex.
Comb’s test,-Direct Appearance
Serology & Immunology

-Indirect Color
Widal Test ‘’O’’ Microscopy
‘’H’’
Weil Felix (OX-19)
Rheumatic Factor
HBs-Ag Bacteriology
HCV-Ab Gram stain
Bacteriology

ASO titer
RPR / VDRL AFB
H.Pylori -Ag (Stool)
H.Pylori –Ab (Serum) Wet mount

Appearance Microscopy Mycology

Myco

Color Crystal KOH

Dipistic Electrolyte panel
Electro

Protein Epithelial cells Sodium

Urinalysis

Glucose Potassium
Ketone Casts Calcium
PH Body Fluid Analysis, Specify=
Body Fluid

S.G. Parasites Appearance Protein

Blood Color Glucose
Leucocyte Cell count LDH
Nitrite Differential,-Gra AFB
Urobilinogen Urine HCG -Lym Gram stain

Reported by______________________________________________Signiture______________________Date & Time________________

Verified by_______________________________________________Signiture______________________Date & Time________________