URINALYSIS Urinalysis Report Form - Pro Advantage by NDC

URINALYSIS Patient Name: _____ Age: _____ q Male q Female Physician’s Name...

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URINALYSIS

Urinalysis

Report Form Patient Name: ________________________________________________________ Age: ___________

q Male

q Female

Physician’s Name: _____________________________________________________ Collection Date: _____________ Test Date: __________ Tester’s Initials: _______

Physical Characteristics: Color: q Colorless q Green

q Yellow q Red

q Amber q Other

q Orange

Appearance:

q Hazy

q Cloudy

q Turbid

q Clear

Chemical Measurements: (circle one) Normal

2

4

8

Glucose (mg/dL)

Negative

50

100

250

Ketone (mg/dL)

Negative

trace/5

+/15

++/40

Urobilinogen (mg/dL)

Bilirubin

Negative

Protein (mg/dL)

Negative

Nitrite

Negative

+ trace

500

++

+++

+/30

++/100

Leukocytes

Negative

trace

+

++

+++

Negative

trace

mod

trace

+/small

Non-Hemolyzed

pH

+++/300 ++++/2000

Positive (any pink color is considered positive)

Blood

Specific Gravity

1000

+++/80 ++++/160

++/mod +++/large

Hemolyzed

5

6

6.5

7

8

9

1.000

1.005

1.010

1.015

1.020

1.025

1.030

Microscope Examination: WBC _____________ /HPF

Crystals ______________

Spermatozoa __________

RBC _____________ /HPF

Bacteria ______________

Artifacts ______________

Casts _____________/LPF

Yeast ________________

Other ________________

Epithelial Cells______/HPF

Parasites _____________

Comments: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ www.ProAdvantagebyNDC.com