De La Salle Medical and Health Sciences - College of Medical Laboratoy Science MT-MLS208 (Clinical Parasitology)
PATHOLOGY Parasitology Requisition
SAMPLE REF. NO.
DEPARTMENT _____________________
No. 567 Mangubat Avenue, Barangay
DATE COLLECTED
Sampaloc, Dasmariñas, Cavite, 4114,
Philippines _____________________
Section 1 - Patient Information
PATIENT SURNAME PATIENT FIRST AND MIDDLE NAME
HOSPITAL ID NUMBER DATE OF BIRTH AGE GENDER
2425-21
M F UNK
PATIENT COMPLETE ADDRESS: #178 Sampaguita Street, Barangay San Juan I, Dasmariñas City, Cavite, 4114
Section 2 - Healthcare Provider Information
ORDERING PHYSICIAN
Dr. Cristina Yang
Section 3 - Test(s) Requested
OVA & PARASITES BLOOD & TISSUE PARASITES PARASITE IDENTIFICATION
Sample Microscopic Examination Request for: Sample
/ Feces Urine / Malaria Worm Proglottid
Other, specify:___________________ Other, specify:
________________________________
Signs / Symptoms
Diagnosis Confirmation ________________________________
Asymptomatic
Diarrhea
Fever Referring Lab Tests Results for Malaria Tick
Other:___________________ Positive Thin and/or Thick Smear Sources of Tick
Duration:____________________ Positive dipstick (Rapid Test) Human Dog Cat
Dipstick (Rapid Test) not done Other, specify:
High Risk Setting Negative Thin and/or Thick Smear _________________________
Immigration (Specify below) Negative dipstick (Rapid Test)
Travel within past 12 months, specify _________________________
below: Sample
__________________________________
Thick and thin blood smear(s) Name of Pet/Owner (If not
______________________
EDTA Blood noted as patient above)
SPECIAL TESTS Tissue/Biopsy, specify: _________________________
Strongyloides concentration/ Isolation Body fluid, specify:
ELISA (Amoebiasis) Other, specify:
Schistosoma Hatch Test (Viability)
Signs and Symptoms
Asymptomatic
Culture for Fever
Acanthamoeba species Rash (Type)
PINWORM Leishmania species
Other, Specify
Sample Other, specify:
_________________________
Sticky paddle (Preferred)
_________________________
Anal swab Signs / Symptoms
Cellopane tape Asymptomatic Fever Skin Lesion
Travel within past 12 months
Eye Other, Specify:_________________
(specify below)
Immigration, specify below
For other available tests and additional information,
________________________________
Travel within past 12 months, specify below:
consult the Seattle Grace Hospital, Pathology ________________________________
__________________________________________
Department eLab handbook at ________________________________
__________________________________________
[Link]/SGH/[Link]
__________________________________________
This requisition and results form is for educational purposes only.
De La Salle Medical and Health Sciences - College of Medical Laboratoy Science MT-MLS208 (Clinical Parasitology)
PATHOLOGY Parasitology Requisition
SAMPLE REF. NO.
DEPARTMENT _____________________
No. 567 Mangubat Avenue, Barangay
DATE COLLECTED
Sampaloc, Dasmariñas, Cavite, 4114,
Philippines _____________________
OVA AND PARASITE EXAMINATION RESULTS FORM
PATIENT SURNAME PATIENT FIRST AND MIDDLE NAME
HOSPITAL ID NUMBER DATE OF BIRTH AGE GENDER
DATE AND TIME OF SPECIMEN COLLECTION DATE OF O&P EXAMINATION
MACROSCOPIC EXAMINATION
Color: _______________________________________
Consistency: _________________________________
Presence of Blood: ☐ Yes ☐ No
Presence of Mucus: ☐ Yes ☐ No
Other Observations: ___________________________
MICROSCOPIC EXAMINATION
Yeast Cells - ___________________
Bacteria - ___________________
Fat globules - ___________________
Charcot Leyden Crystals - ___________________
WBC - ___________________
RBC - ___________________
REMARKS
________________________________________________________
Verified By:
Future Medical Laboratory Scientist Subject Professor
DISCLAIMER
This fictitious laboratory request and results form is intended for academic purposes only. It was prepared by Joseph Dredd Mercado of the College of Medical Laboratory
Science, De La Salle Medical and Health Sciences Institute, for use by his students enrolled in MT-MLS208 (Clinical Parasitology). Please do not distribute without consent
This document was referenced and modified from: Ova & Parasites. (2017). In Parasitology Requisition [Form].Retrieved from
[Link]
This requisition and results form is for educational purposes only.