Lab Report Form | MediTrust Diagnostics

Patient Information

Patient ID

Patient Full Name

Date of Birth

Select Gender

Phone

Date

Pregnancy Status

Specimen type

Ordered by:

Ordered Date

Collected by

Collected Date

Collected Time

Hours

Minutes

Tested by:

Tested Date

Select ordered tests

Liver Function

Total Protein:

Albumin:

Globulin:

Alkaline Phosphatase:

Total Bilirubin:

Direct Bilirubin:

Indirect Bilirubin:

ALT/SGPT:

AST/SGOT:

Gamma GT:

Kidney Function

Creatinine

Urea:

Uric Acid

Electrolyte Panel

Calcium:

Chloride:

Potassium:

Sodium:

Phosphorus:

Magnesium:

Bicarbonate:

Lipid Profile

Total Cholesterol:

HDL Cholesterol:

LDL Cholesterol:

Triglycerides:

Glucose Metabolism

Fasting plasma Glucose:

Two Hour Post Prandial:

Random plasma Glucose:

Glucose Tolerance Test:

Fasting:

Two Hour:

HbA1c:

Cardiac Markers

Troponin I:0 / 5

Troponin I

Myoglobin:

CK-MB:

CK-NAC:

LDH:

NT-proBNP:

Thyroid Function

TSH:

TT4

TT3

TProcalcitonin (PCT)

Inflammatory Markers

C-RP:

Serum Amyloid(SAA):

Pancreatitis Markers

Amylas:

Lipase:

D-dimer

Creatinine Clearance

Acid Phosphatase

Lab Tech NameEnter your full name

Date

Clinical Chemistry

Patient Lab Test Form