@csrf

Date

General-ID or NAP-ID

Doctor

Counselor

Age

Age(month)

Sex

Risk Factor

Print Type

Patient's ID

Plz put Patient's ID.

Date(dd mm yyyy)

Plz put Patient's Visit Date.

Determine Result

UNI-Gold Result

STAT-PAK Result

Result

Inconclusive follow up

Lab Technician

Comment

Syphillis RDT

Syphillis RDT Result

RPR Test

RPR Result

Titre (Current)

Titre (Last Visit)

Last Titre Date

Comment

Lab Technician

pmnl_urethra

		Gram Stain
	Urethra	Post, fornix	Endo cervix	Rectum
Clue Cells %
PMNL cells / HPF
Trichomonas
Gram (-) diplococci intra/extra cell
Gram (-) diplococci extra cell only
Candida
Spermatazoites, RBCs, others:

Urine Exam (FPU)
Gram(-) diplococci intra-cell		Epithelial cells
Gram(-) diplococci extra-cell		PMNL cells
Other Bacteria(Gram Stain)

Lab Technician

Type of Test

Appearance(Colour)

Turbidity

Pus/ WBC

Protein

Glucose

RBC

Leukocyte

Nitrite

Ketone

Epithelial Cell

Urobilinogen

Bilirubin

Erythrocyte

Crystal

Haemoglobin

Cast

Analyzer (2 CE)Results

Cretinine (mg/dl)

Albumin(mg/L)

A : C (ratio)mg/g

Comment

Lab Technician

Urine TB LAM

Toxoplasma Antibody

IgG

IgM

Serum Cryptococcal Antigen

Dilution

CSF for cryptococcal Antigen

Dilution

CSF Smear

Giemsa stain Result

India Ink Result

Skin Smear

Giemsa stain Result

India Ink Result

Other

Result in text

Result

Lab Technician

Dangue RDT Test

NS1 Antigen

IgG

IgM

Malaria RDT

RDT Result

Malaria Microscopy

Species

Grade

Stages

RBS Result (mg/dl)

FBS Result (mg/dl)

Haemoglobin % (g/dl)

HbA1C (%)

Lab Technician

Stool RE Test Done

Colour

WBCs/ PUS cell

Consistency

RBCs

Other

Comment

Lab Technician

Previous Tretment TB

HIV Status

Reason for examination

Diagnosis/Followup

Follow Up Month

Specimen type

Sample 1

Sample 2

Slide Number

Specimen received date

Visual Appearance

AFB Result

Scanty Grading

Lab Technician

Type of Patient

Specimen Type

Other Specify

Test Type

Result

Lab Technician

Comment

ART initiation

ART duration(Months)

Sample shipment date

Sample sent to

Other Organization Code

Result Received date

Detectable

Viral Load Result

Remark

Form

Choose test...

Laboratory Result Form
(Office Lab)

Patient ID

Age(Y)

Gender

Fuchia ID

Age(M)

Requested MD

Counselor

Specimen collection
date & time

Test Name

Result

Test Name

Result

HIV (Ab)

OI tests

Determine

TB LAM

Uni-gold

Toxoplasma Ab

Stat Pak

Serum Crypto Ag

Dilution

Final Result

CSF Crypto Ag

Dilution

Hepatitis B&C

CSF smear

HBs Ag

Gram stain

HCV Ab

India Ink (WM)

Syphilis

Skin smear

Other

RDT

Gram stain

RPR

India Ink (WM)

Current titre

General tests

Last Titre

Dengue RDT

Urine Dipstick

Normal

Malaria RDT

Appearance - Colour

(Pale yellow)

Malaria microscopy

Turbidity

(Clear)

Covid Ag RDT

4.5-8

Normal

Protein

(Nil)

RBS

(< 140mg/dl)

Glucose

(Nil)

FBS

(< 100mg/dl)

Leukocyte

(Nil)

Hb%

(M: 13 - 17, F: 11.5 - 15.2 g/dl)

Nitrite

(Nil)

HbA1c %

(4.5 - 6.3%)

Ketone

(Nil)

Stool RE

Urobilinogen

(Nil)

Colour

Consistency

Bilirubin

(Nil)

WBC

RBC

Erythrocyte

(Nil)

Other

Haemoglobin

(Nil)

AFB Microscopy

Urine microscopy

Sample type

WBC

(<5/HPF)

Sample 1

Sample 2

RBC

(<5/HPF)

Slide Number

Epithelial cell

(<10/HPF)

Visual appreance

Crystal

(Nil)

AFB Result

Cast

(Nil)

Scanty grading

STI (Gram stain smear)

PMNL/HPF normal (Male <5, Female <20)

Wet Mount

Urethra

Posteria Fornix

Endocervix

Rectum

Urine for GC

Clue Cells%

PMNL /HPF

Trichomonas

GC Intra

GC Extra

Candida

Other

Remark

Lab Tech

Issue Date

Office Lab

Biochemistry and CP Tests

Patient ID :

Fuchia ID :

Gender :

Age(Y) :

Age(M) :

Req MD :

Clinic :

Counselor :

Specimen Collected Date:

HIV (Ab)(Verification)

Bio tests

Test

Result

Test Name

Result

Unit

Ref

Determine

Total Bilirubin

mg/dl

0.1 - 1.2 mg/dl

Uni-Gold

ALAT (SGPT)

U/L

Male:≤45, Female:≤34 U/L

STAT-PAK

AST (SGOT)

U/L

Male:<35,Female:<31U/L

Result

ALP

U/L

Adult:44-147U/L,Child: < 362U/L

CD4 and CD4 % Result

GGT

U/L

Male: ≤ 55, Female: ≤ 38 U/L

CD4 result

Albumin

g/dl

3.5 - 5.5 g/dl

CD4% result

Total Cholesterol

mmol/L

< 5.17 mmol/L

ART start Date

HDL Cholesterol

mmol/L

M:0.77-1.81, F:0.77-2.19mmol/L

WHO Stage

LDL Cholesterol

mmol/L

< 3.36 mmol/L

Triglycerides

mmol/L

< 1.71 mmol/L

Urea

mg/dl

17 - 43 mg/dl

Creatinine

mg/dl

Male:0.8-1.3,Female:0.6-1.2mg/dl

Calcium

mg/dl

8.6 - 10.3 mg/dl

Phosphorus

mg/dl

2.7 - 4.5 mg/dl

Uric Acid

mg/dl

Male:3.5-7.2,Female:2.6-6.0mg/dl

HbA1C

4.5 - 6.3 %

sec

10-14

INR

Complete Picture

Comment

Lab Tech::

Issue Date::

Laboratory Result Form(Office Lab)

Biochemistry and CP Tests

Laboratory Result Form
(Office Lab)