Urinalysis Report Form at a glance
What it is: Patient Name, Age, Physician's Name, Collection Date, Test Date and Tester's Initials: The Urinalysis Report Form has lines.
Who signs: Write the Tester's Initials.
A filled-in Urinalysis Report Form example: a tester fills out the report for one patient
How to fill out Urinalysis Report Form, box by box
Patient Name and Test Date
Fill in Patient Name, Age (M or F), Physician's Name, Collection Date and Test Date.
Write the Tester's Initials.
Physical Examination
Under Physical Examination, mark the Color as colorless, yellow, amber or other, and the Appearance as clear, hazy, cloudy or turbid.
Chemical Examination (circle one)
Chemical Examination (circle one).
specific gravity: 1.000, 1.005, 1.010, 1.015, 1.020, 1.025 or 1.030.
pH: 5, 6, 7, 8 or 9.
leukocytes: neg, trace, + or ++.
Nitrite is neg or pos; any pink color is considered positive.
protein (mg/dL): neg, trace, +/30, ++/100 or +++/500.
glucose (mg/dL): normal, 50, 100, 250, 500 or 1000.
ketones: neg, +small, ++mod or +++large.
urobilinogen (mg/dL): normal, 1, 4, 8 or 12.
bilirubin: neg, +, ++ or +++.
blood (ery/µl): neg, trace, 50 or 250.
hemoglobin (ery/µl): 10, 50 or 250.
Comments
Write Comments on the lines.
Sources
[1] Urinalysis Report Form, a generic template with no single issuer file (the Official source link on this page).