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TRF Format

The document is a Test Request Form used by Maharshi Devraha Baba Autonomous State Medical College for collecting patient information and requesting laboratory investigations. It includes sections for patient details, sample details, clinical information, and a list of various tests that can be requested. The form also allows for additional investigations and requires the signature of the requester and the date.

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64 views1 page

TRF Format

The document is a Test Request Form used by Maharshi Devraha Baba Autonomous State Medical College for collecting patient information and requesting laboratory investigations. It includes sections for patient details, sample details, clinical information, and a list of various tests that can be requested. The form also allows for additional investigations and requires the signature of the requester and the date.

Uploaded by

badboy5637430
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Test Request Form-Format

(Maharshi Devraha Baba Autonomous State Medical College, Deoria, UP)


Patient Details:
Name of Pt.: ……………………………………………
Age/Gender: ………………………………………….. Urgency: Normal 
OPD/IPD: …………………………………………..
Ward/Bed (if IPD): ………………………………………….. Urgent 
Department: …………………………………………..
Reason if urgent:…………………………………………………
Dr Name: …………………………………………..

Sample Details: Collected By-


Collection Date-
Collection Time-
Type of Sample- Blood Urine Sputum Faeces Fluid
Other;…………………………………………

Relevant clinical information/Provisional diagnosis:


……………………………………………………………………………………………………………………………….
Investigation requested:
 CBC  Fasting blood sugar  Indirect bilirubin
 ABO/Rh typing  Post prandial blood sugar  Serum ALP
 GBP  Random blood sugar  BUN
 Urine R/M  LFT  Serum Urea
 PT/INR  KFT  Serum creatinine
 aPTT  Serum Electrolyte  Serum total Calcium
 ESR  Thyroid Profile  Lipid Profile
 Hb  FT3  Serum Vit B12
 TLC  FT4  Serum Vit D
 DLC  TSH  Serum Oestrogen
 Platelet Count  Serum Progesteron
 Serum iron profile
 Malaria Rapid Card  Serum testosterone
 Serum Prolactin  Serum Uric Acid
 HBsAg rapid card  Serum PSA Others…………………………………………
 HCV rapid card  HbA1C …………………………………………………
 HIV rapid card  Total bilirubin …………………………………………………
 Dengue rapid card  Direct bilirubin …………………………………………………

Additional Investigation (if required)


………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Signature of the requester
Date

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