Page 123 - Buku Panduan Perkhidmatan MKAKB

MKAK-BPU-D02(rev_Nov_2015)
MAKMAL KESIHATAN AWAM KEBANGSAAN, KEMENTERIAN KESIHATAN MALAYSIA
Lot 1853, Kg Melayu Sungai Buloh, 47000 Sungai Buloh, Selangor Darul Ehsan
Tel: 03-615 65109 Fax: 03-614 02249/615 69654
LABORATORY REQUEST FORM FOR DENGUE AND FLAVIVIRUS
Lab No. (for lab use) :

REQUESTOR INFORMATION
Name :

Post :
Address :

District : State :

Tel. No. : Fax No. : Email :

Purpose of Sampling
a. Dengue (please tick purpose of sampling as b. Flavivirus (please tick purpose of sampling

below) as below)
Outbreak Outbreak

Surveillance Surveillance

Diagnostic Diagnostic

Specimen Category : case Contact

A. PATIENT’S INFORMATION

Name : Age : Date of birth

Sex : Male Female

IC No.
Reference No. : Nationality : Malaysian Non Malaysian

Address (Please state country of origin) ____________
Postcode : Occupation :

District : State : Tel. No. :

B. CLINICAL SUMMARY
o
Fever : T ……. C Diarrhea Laboratory findings at admission

Retro-orbital pain Bleeding tendencies Hb : TWBC : (PN : %; L: %; M : %; E: %)

3
Maculopapular rash Hepatomegaly Platelets : /mm HCT :
Vomitting Shock Dengue NS1 : Date of test :

Myalgia/arthralgia CNS Complications Method :

Dengue IgG : Date of test :
Date of fever onset : (dd/mm/yyyy) Method :

Dengue IgM : Date of test :

Method :

Clinical/Provisional Diagnosis :
Dengue Fever Dengue Hemorrhagic

Dengue Shock Syndrome Death : (dd/mm/yyyy)

Compensated Shock Other (flavivirus).

C. PATIENT’S LOCATION
Clinic Ward ICU

D. SPECIMEN INFORMATION

Type of specimen : Name of Collector :

Date of Collection: (dd/mm/yyyy) Date specimen Received (for lab use) : (dd/mm/yyyy)

E. RESULTS (for lab use only)

Verified by : Date:

Buku Panduan MKAKB 88