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Page 1: Lampiran 3

FORM PEMERIKSAAN LABORATORIUM

Jl. Raya Rajeg No.1 Tangerang Banten, Indonesia 15540Tlp : 021- 5578946, FAX : 021- 5576894, Email : [email protected]

Nama : ................................................... Dr. Patologis : ...........................................Umur : ................................................... Rumah sakit : ...........................................Jenis Kelamin : ................................................... No. Rekam Medis : ..........................................Alamat : .................................................... ....................................................No. Tlp : ....................................................

HEMATOLOGI KIMIA KLINIK IMUNOSEROLOGI

LED

Darah Rutin (Hb, Ht, Leukosit, Eritrosit, Trombosit)

Darah lengkap (Hb, Ht, Leukosit, Trombosit, Eritrosit, Indeks Eritrosit (MCV, MCH, MCHC), Hitung Jenis Leukosit.

Faktor pembekuan darah (PT, aPTT, TT, Kadar Fibrinogen, D-Dimer)

Glukosa Darah Puasa*

Glukosa Darah Sewaktu

Glukosa Darah 2 jam pp*

Kolesterol total

Kolesterol HDL

Kolesterol LDL

Trigliserida*

PAKET LIPID (Koloesterol, HDL, LDL, Trigliserida)

SGOT

SGPT

Asam Urat

Ureum*

Kreatinin

Golongan Darah

Widal**

HBs Ag (Hepatitis B )

Anti HBs

Keterangan :

* pasien diwajibkan puasa terlebih dahulu 10 – 12 jam

** pemeriksaan dilakukan 4 – 7 hari setelah demam

DATA DIRI PASIEN

JENIS PEMERIKSAAN