Urine Analysis Laboratory Request Form
Patient Name
Age
Sex
Patient ID
Date
Physician
Ward/Clinic
Clinical Information
Requested Tests
Routine Urinalysis
Urine Culture
Others (specify)
Laboratory Results
Test
Result
Remarks
Color
Appearance
Specific Gravity
pH
Protein
Glucose
Ketones
Bilirubin
Urobilinogen
Blood
Nitrites
Leukocyte Esterase
Epithelial cells
WBC/hpf
RBC/hpf
Casts
Crystals
Bacteria
Others/Comments
Laboratory Scientist
Signature
Date