Urinary System Lab Report Form
Please complete this form to document laboratory findings for urinary system evaluation.
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sample Collection Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Sample Type
*
Please Select
Midstream urine
First morning urine
Catheter urine
Random urine
Other
Urine Color
*
Please Select
Straw
Yellow
Amber
Red
Brown
Other
Urine Clarity
*
Please Select
Clear
Slightly cloudy
Cloudy
Turbid
pH Value
*
Protein
*
Please Select
Negative
Trace
1+
2+
3+
4+
Glucose
*
Please Select
Negative
Trace
1+
2+
3+
4+
Additional Notes / Observations
Submit Report
Should be Empty: