Request form

Intermediate Reference Laboratory

Department of Pulmonary Medicine & Sleep Disorders
Room No. 41, DOTS Centre
·I lab iD :
_ Date : _ _ _ __
All India Institute of Medical Sciences, New Delhi-110029
Name • ............................................................................................... Age/Gender : ........................... UHID No. : ..................................
Add-ress : ............................................................................................ Mob. No. : ............................ Referral Site : .................................
Nature of Specimen : Test requested :
Sputum D . Microscopy (AFB)
Pleural Fluid □
Peritoneal Fluid □ GeneXpert
□
Ccrcbrospinal Fluid □ Line Probe Assay (LPA)
□
Lymph node aspirate/biopsy/Cold abscess □ Solid Culture (LJ)
□
Bone marrow aspirate/biopsy
0 Liquid Culture (MGIT-960)
□
Urines □ Drug Sensitivity Testing
□
Others (Specify) □
□
Clinical Diagnosis Tubercu'losis Treatment Status

Involved organ/system
Treatment Naive D
Lymph•Node
Treatment Experienced D
ATT Category : Cat-I O Cat-II O Cat-IV 0
Axillary D Cervical
Mediastinal D fnguinal □ Name of the drugs taken: .. ......................................... ................
Mcscnteric D Retroperitoneal □
□
CNS Period and duration of treatment: ................................... :.........
. . Meningitis
□ Tuberculoma
□ Radiological Imaging

lntralhora·cic
Pleural Effusion
Lymphadenopathy □ Pericadial Effusion
□
□ Histopathological Diagnosis
Abdominal
Cytology Report
□
Ascites
□
Lymphadenopathy
□
Intestinal
Histopathology Report
□
Gcnito-urin~ry

Skeletal
Shoulder O Hip
□
Biochemical Analysis
Knee Ankle D □
Fluid Analysis
D
Elbow
Small Joints-Hands
Pelvis
D
Wrist .
Small Joints - Feet
D ·
8- ADA
Glucose
Albumin
Spine: Cervical D Thoracic D Lumbar D Sacral □ LDH
Cytology
Disseminated (Specify Involvement)
Total cell count
Others · Differential count: L N M E

Response to treatment/follow-up Other Relevant Investigations

Symptomatic improvement
□ HIV status D
Radiological improvement 0
□
Others

Name of Physician Signature (with Stamp)

(Unit Head) Date:

Yes - 1, No -1, Unknown-2

• (Incomplete form will not be accepted)