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Nhsbi Form To Deepen Understanding
Nhsbi Form To Deepen Understanding
I declare that the information given above are TRUE and CORRECT. ________________________________________________________
Print Name and Sign (Examinee or Accompanying Parent/Guardian if 16 yrs old and below)
Please encircle relation to examinee: Father / Mother / Grandmother / Grandfather / Uncle / Aunt / Guardian / Brother / Sister
FOR NHSBI STAFF ONLY
TIME IN TIME OUT INITIAL
CPE, Urinalysis, RPR, HIV, Hbsag, Anti-Hcv, FCBC, HBA1C, eGFR, CXR
INITIAL INTERVIEW:
CPE, Urinalysis, RPR, HIV, Hbsag, full CBC, Crea, LFT, CXR
CPE, Urinalysis, HIV, Hbsag, Anti-HCV, CXR CONSENT:
CPE, Urinalysis, RPR, HIV, CREA, CXR SCAN/PICTURE:
CPE, FCBC, EGFR, CXR OTHER TESTS PRE-EXAM:
UA-Dipstick IGRA
CPE, Urinalysis, HIV, CXR CASHIER: CASH/ADV DEPOSIT
UA-Microscopy CALCIUM
CPE, Urinalysis, CXR PREG TEST HBeAG RECEIPT/LOGBOOK
CPE, CXR HIV HBV - DNA LABORATORY: URINALYSIS
HBSAG Liver Fibro Scan
CPE, Urinalysis ANTI-HCV ECG BLOOD TEST
CPE Only FBS CHEST UTZ DOH
NHSBI METRO LIPID PROFILE LGBP UTZ ADD'L TEST
S. CREA CXR - PA
DEPOSIT BUA CXR - APL
AFP CXR - APICO CHEST X-RAY: PA VIEW
CASH LFT CXR - R LAT
To tal M edical ADD'L VIEW
To tal Cash P aid SGPT CXR - L LAT
Fee
FCBC CXR - LOR
Signature Change
EGFR CXR - R OBL HEIGHT AND WEIGHT:
TPPA CXR - L OBL
A dd'l Fee A dd'l Fee UPC CXR - SPOT PHYSICAL EXAM:
FERRITIN PPD REFERRAL:
A dd'l Fee A dd'l Fee
SPUTUM
To tal A dd'l Fee To tal Cash P aid
INSTRUCTED:
Signature Change
FINAL INTERVIEW: WAITING AREA
TOTAL MEDICAL FEE PAID (2ND FLOOR EXTENSION AREA)
Pertinent Laboratory Findings: circle/highlight/add required tests (MARK "N" for NORMAL RESULTS)
_UA_ RPR _HIV HBSAG ANTI-HCV _CXR_ EGFR FCBC HAIC RPT UA CREA _ECG_ LFT_ LGBP FBS_ FLIPID _____ ______ __ ___ ______