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Pt. Jakarta Kyoai Medical Center (TEL: 572-4330 FAX: 572 - 4331)

1. This document appears to be a medical test requisition form from PT. JAKARTA KYOAI MEDICAL CENTER listing various tests that can be ordered including urinalysis, urine sedimentation, hematology, ESR, CRP, stool test, carbo-metabolism, lipids, liver function, renal function, and hepatitis and other screening tests. 2. The form includes spaces to note the patient's results for each test, the doctor's notes, and spaces for the doctor's signature and date. 3. Reference ranges are provided for many of the tests to indicate normal ranges.

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Annisa Septyani
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104 views1 page

Pt. Jakarta Kyoai Medical Center (TEL: 572-4330 FAX: 572 - 4331)

1. This document appears to be a medical test requisition form from PT. JAKARTA KYOAI MEDICAL CENTER listing various tests that can be ordered including urinalysis, urine sedimentation, hematology, ESR, CRP, stool test, carbo-metabolism, lipids, liver function, renal function, and hepatitis and other screening tests. 2. The form includes spaces to note the patient's results for each test, the doctor's notes, and spaces for the doctor's signature and date. 3. Reference ranges are provided for many of the tests to indicate normal ranges.

Uploaded by

Annisa Septyani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PT.

JAKARTA KYOAI MEDICAL CENTER


( TEL : 572- 4330 FAX : 572 – 4331 )
1. Urinalysis 7. Carbo - Metabolish
SG : Protein : ( ) B. Glucosa FASTING =60- mg/dl
pH : U.Blood : ( ) HbA 1c 110 %
PP = < 140
Gluco : ( Keton : ( )
4.5 – 6.0
)
Urobi : ( 8. Lipid
)
2. Urine Sedimentation Triglyceride 35 – 160 mg/dl
RBC : - Bact : ( ) T-cholesterol 130 – 230 mg/dl
WBC : - Other : ( ) HDL-Chol 35 - 851 mg/dl
Epith : ( 9. Liver Function
)
3. Hematologi T.BILL 0.20 – 1.30 mg/dl
RBC M 400 – 570 X104/l ALP 40 – 130 IU/l
F 350 - 500
Hb M 14 – 18 g/dl LDH 310 – 620 IU/l
F 12 - 16
Ht M 40 – 50 % GOT 8 – 57 IU/l
F 36 - 48
MCV 80 – 100 fl GPT 9 – 72 IU/l
MCH 27 – 32 pg -GTP 0 - 72 mU/ml
MCHC 30 – 35 % 10. Renal Function
PLT 15 – 40 X104/l BUN 7.0 – 21.0 mg/dl
WBC 4.0 – 10.0 X103/l CRE 0.7 – 1.5 mg/dl
4. ESR M 0 – 10 mm/1hour UA mg/dl mg/dl
F 0 - 15
5. CRP N : < 10 mg/l 11. HAV Ab
6. Stool Test 12. HBs Ag
a. OB 13. Hbs Ab mU/ml
b. Parasite 14. HCV Ab
Other Test

Note :

Result : (Doctor) ____________________


Wait : Fax :

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