Name :______ _________________________ Age: _____ Sex: _____ Specimen No: _____

Family Name First Name

Date: ___________________

MM/DD/YYYY

URINALYSIS

PHYSICAL EXAMINATION

Color: __________________ Transparency: _______________________

CHEMICAL EXAMINATION

Glucose: ______________ pH: ______________________

Bilirubin: ______________ Blood: _____________________

Ketones: _______________ Urobilinogen: _______________

Specific Gravity: __________ Nitrite: ____________________

Protein: ________________ Leukocyte esterase: ____________

MICROSCOPIC EXAMINATION

Squamous Epithelial Cells: ___________/lpf Red Blood Cells: __________________/hpf

Mucous Threads: _________________/lpf White Blood Cells: ________________/hpf

Casts: _________________________/lpf Oval Fat Bodies: __________________/hpf

Abnormal Crystals: ________________/lpf Renal Tubular Epithelial Cells: _________/hpf

Normal Crystals: __________________/hpf Bacteria: ________________________/hpf

Others: ___________________________________________________________________

_____________________________ Question 1: _____

Medical Technology Student Question 2 : _____

Question 3 : _____

Question 4 : _____

Noted and checked by: Total Score: _____________

_________________________________
KARL MAXEL O. LAO, RMT
College Instructor/Medical Technologist
License No. 105924
Name: ____________________________ Age: _____

Date: ____________ Sex: _____

Specimen No.: __________

FECALYSIS

PHYSICAL EXAM

Color: ____________ Consistency: _____________

MICROSCOPIC EXAM

Pus Cells: _____________/hpf Yeast Cells: ________________/hpf

Red blood cells: _________/hpf Fat Globules: _______________/hpf

Bacteria: ______________/hpf

REMARKS: ________________________________________________________________

Performed by: Noted by:

___________________ Karl Maxel O. Lao, RMT

Medical Technology Student Instructor