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General Purpose Investigation Form

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richardeldad5
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97 views1 page

General Purpose Investigation Form

Uploaded by

richardeldad5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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Version 2.

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MOHCDGEC001 Effective date: August 2016

MINISTRY OF HEALTH AND SOCIAL WELFARE

GENERAL PURPOSE DIAGNOSTIC INVESTIGATION FORM


Name of Hospital: _________________________________________ Hospital registration number: ______________________________________________
Address of Hospital:________________________________________ Surname (in Capitals):______________________________________________________
Email: ___________________________________________________ Middle name (in Capitals):__________________________________________________
District: _______________________ Region: ___________________ First name (in Capitals): ____________________________________________________
Request to : ______________________________________________ Date of Birth: ______/_______/_______ Age: __________ Sex: £ F £ M
£ Clinical Laboratory Postal / Residential Address: ______________________________________________
£ Microbiology £ Clinical Chemistry
£ Haematology £ Blood Bank Email: ____________________________________ Mobile: ________________________
£ Histopathology/Cytology £ Parasitology
£ Toxicology £ DNA Occupation: ______________________________________________________________
£ Other (Specify):_______________________________
£ X-ray Department £ EEG - Room £ ECG - Room
£ MRI £ Other (Specify):______________________ Clinic / Ward: _____________________________________________________________
Clinical Notes relevant for the requested investigation:

Diagnosis (indicate if provisional or confirmed):

Specimen Information
Nature of Specimen: □ Blood □ Stool □ DBS □ Sputum □ Urine □ Tissue □ Semen □ Fluid (specify)______________________________
□ Swab (type)_______________ □ Other (Specify)___________________ Investigation/Specimen Number:_________________
Collector's Name:_________________________ Signature:________________ Collection Date: ____/_____/____ Collection Time: ______:_____
Received in lab by:_____________________________ Signature:______________________ Date: _______/_________/______ Time: ________:________
Information needed for Investigation:
Previous Diagnostic imaging Blood for Transfusion
Number Date Blood Group Hb Number of Units required Required how soon
____ /____ /______
LMP: Donor: Reason for transfusion:

Requested Investigation (Specify): _________________________________________________________________ Code Number: _______________________

Requested by:__________________________ Signature: ______________________Request Date:_______/________/__________ Time:______ : _______

Firm: ____________________________________________________ Head of firm: ___________________________________________


Report
Investigation Date Time Equipment Used Investigator's name Signature
____/____ /_____ _____:_____

Report Date Time Name of person responsible for report: __________________________________ Signature:____________________
_____/_____/_____ _____:______ Designation: ___________________________________

Reviewed / Authorized by: __________________________ Designation: _______________________ Date:______/_______/_______ Time: _____:______


Remarks:__________________________________________________________________________________________________________________

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