Fillable Laboratory Request Form

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Laboratory Request Form

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The Laboratory Request Form form is 1 page long and contains:

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  • 59 check-boxes
  • 42 other fields

Country of origin: OTHERS
File type: PDF

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
Laboratory Request Form

/

 
:
Province/HealthFacility
：


Date
/
日期


Reasonsfortesting
測試目的





Suspect/
懷疑
Pneumonia/
肺炎

HCW/
医护人员

Migrants/
劳工


  ________________
:
 
ContactwithCOVIDcases
/
新型冠状病毒密切接触者
TypeofcontactDirect Indirect
 


Follow‐up/
複查
Follow‐upCOVIDpatient/
複查
Other/
其他
___________________________
ព័ត៌នអកជំង
ឺ
/Patient
information
/
患者信息
 
PatientName
/
患者姓名

PatientID

Sex
/
性别


Male
/
男
Female
/
女

A
ge
/
年齡

Nationality
/
国籍


Occupation/
职业


Telephone
/
電話
 

A
ddress
/
地址
 ……………………………………….……………………………………
………


Residence
住所
House
家
Street
路号

………….…………………………………………….……………………………….……………
Village
乡村
Commune
公社
District
区
Province
省
 
Clinical
Symptom
临床症状







Fever
发烧
Cough
咳嗽
RunnyNose
流鼻涕
SoreThroat
喉咙痛
DifficultyBreathing
呼吸困难
None
没有症状

Dateofonset
/
发病日期


-?
HistoryofCOVID‐19positive?
你曾
经有过新冠肺炎病毒吗？


:
NoYesTestDate:
没有 有 检测日期


Co‐morbidity










HypertensionDiabetesCardiopathCKDObesityPregnantOther


Travelhistory
/旅行历史
 
/

Province/Country
国家名称

Dateofarrival
到达日
期

/
 

PassportNo/
护照号

SeatNo/
座号




  

1………………………………................2……………………………………………
3………………………………………………4……………………………………………
5………………………………………………6……………………………………………
 
VaccinationStatus


/
1
st
dose


/
2
nd
dose

/
3
rd
dose

/
4
th
dose
Notvaccinated


……………

……………


……………


……………


Sinopharm
Sinovac
AstraZeneca
Johnson&Johnson
Pfizer
Moderna
ែផកមនីរពិេធន
៍
/Laboratory


Placeofcollection


Dateofcollection


Typeofspecimen





Nasopharyngeal
Oropharyngeal
Others……………



IPCNIPH
PKML
NBTC 
SRH
BTB
SHV…………………………………



(គ
ូ
សរងង់)
N
o
ofSample(circle)
12345678910……

/Requestedby………………………………….
/Telephone…………………………..………..
/Collectedby………………………………………………………………..………
/Telephone…………………………
/
Signature…………………………
កំែណៃថងទី ០១ កុមភៈ ២០២២
Updated on 01 Feb 2022
Institut Pasteur du Cambodge
✔
Travel certificate
Institut Pasteur du Cambodge
✔
✔
IPC sampling team
012 812 003
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Laboratory Request Form

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Completed 19 April 2022

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