Download Work Form 4-2

Work Form 4-2
URINALYSIS REPORTING FORM
Tested By:
Time:
Doctor:
Location
Leukocytes
Nitrite
Urobilinogen
Protein
pH
Negative 
Blood
Specific
Gravity
Ketone
Negative 
Bilirubin
Negative 
Glucose
Negative 
Date:
Trace 
Negative 
Small+ 
Positive 
Moderate++ 
(Any degree of pink color is Positive)
Normal 
Normal 1 
2
4
8
Negative 
Trace 
30+ 
100++ 
300+++ 
5.0 
6.0 
NonHemolyzed
Trace 
1.000 
1.005 
Negative 
mg/dL
g/dL (%)
mg/dL
Large+++ 
6.5 
NonHemolyzed
Moderate 
7.0 
Hemolyzed
1.010 
Trace
1.015 
Small
1.020 
Moderate
5 
Small
+ 
1/10 (tr.)
100 
15 
Moderate
+ + 
¼
250 
40 
Large
+ + + 
½
500 
Trace 
7.5 
Small
+
2000 or more
++++
8.0 
Moderate
++
8.5 
Large
+++
1.025 
Large
1.030 
Large
50 
150 


1
2 or more
1000 
2000 
or more
Microscopic
WBC ___________________/HPF
EPITHELIAL CELLS ______/HPF
APPEARANCE ______________
RBC____________________/HPF
TYPE ________________________
ODOR ______________________
CASTS __________________/LPF
TRICHOMONAS ______________
COMMENTS _________________
TYPE _______________________
BACTERIA ___________________
_____________________________
CRYSTALS __________________
OTHER ______________________
_____________________________
YEAST ______________________
COLOR_________________________
_____________________________