Urine Culture and Sensitivity Test Report Form
Record patient and specimen details, culture findings, organism identification, antibiotic sensitivity, and interpretation.
Patient Full Name
*
First Name
Last Name
Patient Age (years)
*
Patient Gender
*
Male
Female
Other
Specimen Collection Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Specimen Type
*
Please Select
Midstream Clean Catch
Catheter
Suprapubic Aspiration
Other
Clinical Notes / Indication
Culture Findings
*
No Growth
Significant Growth
Mixed Growth
Organism Identified
*
Please Select
Escherichia coli
Klebsiella species
Proteus species
Enterococcus species
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Other
Antibiotic Sensitivity Results
*
Rows
Sensitive
Intermediate
Resistant
Amoxicillin-Clavulanate
1
2
3
Ciprofloxacin
4
5
6
Nitrofurantoin
7
8
9
Ceftriaxone
10
11
12
Gentamicin
13
14
15
Cotrimoxazole
16
17
18
Imipenem
19
20
21
Final Interpretation / Recommendation
*
Submit Report
Should be Empty: