OCUPATIONAL HEALT

Date Published: [10 Feb 2020] Revision: Page:

FORM Document Classification : Restricted

Reference Document No.

Document No.

CLINIC REGISTRATION LABORATORY FORM

NAME : DOCTOR :
DATE OF BIRTH : DATE :
NO. MEDREC : Clinical Notes:
COMPANY :

TYPE OF BLOOD CHECK

HEMATOLOGY HEMATOLOGY BIOCHEMISTRY BIOCHEMISTRY

□ HGB □ Differential Count □ Glucose Fasting □ Urea
□ RBC Neutrophils □ Glucose 2-hour pp □ Creatinine
□ WBC Lymphocytes □ Glucose Random □ SGOT
□ HCT Monocytes □ Uric Acid □ SGPT
□ PLT □ Malaria Smear □ Chol-T
□ MCV □ Blood Group □ HDL
□ MCH □ LDL
□ MCHC □ Triglyceride
□ LED

SERO IMMUNOLOGY URINALYSIS URINALYSIS LAIN-LAIN

□ HbSAg □ Macroscopic □ Microscopic □ Alcohol Test
□ HCV Color WBC
□ HIV Turbidity RBC
□ IgM Dengue pH Crystal
□ IgG Dengue Ketones Bacteria
□ Malaria Rapid Test Blood Epthelia
□ Widal Bilirubin □ Pregnancy Test
S. Gravity □ Drug Test
Protein
Nitrit
Leukosit
Uro Bilinogen
 Glucose
If you result has finished, pleace sign
below
Lab Analyst : Date : Doctor:

Cindi Nurlaela Sari Amd. Anakes

age:

tion : Restricted

BIOCHEMISTRY
Urea
Creatinine
SGOT
SGPT

LAIN-LAIN
Alcohol Test
octor: