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BASIC PATIENT INFORMATION

Ward #: ______   Bed #:______

Name:  Surname_____________________   Given names_____________________

Sex:  Male    Female               

A ge : _____    YEARS  or  MONTHS (for children under 1 year)

 

 

PRESCRIBER INFORMATION

Requested by (print your name): _________________________________             

Title: ________________________________________________________

 

 

 

 

LAB TESTS (PHE)

New admission (Malaria RDT + Ebola PCR)

Repeat Ebola PCR

 

 

 

 

LAB TESTS (MoD)

Full Blood Count (purple)                                                                                                                                 

Coagulation screen (blue)     

 

Amylyte 13 (green)

       OR                                                                                                                               

Metlac 12 (green)                                         

 

Special request

      D-Dimer

      HIV                                                                              

      Blood culture   

      Dengue