Microscopic Discharge Examination Form
Record essential details for a microscopy-based discharge examination. Please complete all fields accurately.
Sample Identifier
*
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Department or Clinician
Specimen Source/Type
*
Please Select
Vaginal
Urethral
Cervical
Other
Macroscopic Appearance
Please Select
Clear
Cloudy
Purulent
Bloody
Other
Microscopic Findings
*
Presence of White Blood Cells
*
None
Few
Moderate
Many
Organisms Observed
Bacteria
Yeast
Trichomonas
Clue cells
Other
Preliminary Interpretation
Examiner Name
*
Submit Examination
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