Laboratory Request Form
Department of Microbiology, King Chulalongkorn Memorial Hospital
1873 Rama IV Rd., Pathumwan District, Bangkok 10330, Thailand Tel. 0-2256-4132 Fax 0-2252-5952
Name………………………….….……………. Sex r M r F Age………yrs. Clinic/Ward……..………... HN………………..… AN…………..………. Requested by / Code………………….. Diagnosis…….…...…….
VIROLOGY HIS Lab No. MV..………..…….…….
SPECIMEN : Must be filled in completely : Collection Date …………… Time ………. By …………. Antiviral treatment rYes (ระบุ)..................rNo st nd Genitourinary tract Blood rClotted r1 serum r2 serum Respiratory tract rEDTA rHeparin rNasopharyngeal aspirate rNasopharyngeal swab rCervical swab rVaginal swab rBone marrow rEndotracheal aspirate rNasal swab rUrine rCSF rBronchoalveolar lavage (BAL) rThroat swab Gastrointestinal tract rStool rRectal swab rGastric content Eye rConjunctival swab rVitreous fluid Skin lesions rSkin scraping/swab rVesicle fluid rOther…………………………………………..(ระบุ) rCorneal scraping rTear
Adenovirus rMV059 Adenovirus Ag (Rapid) rMV063 Adenovirus isolation* rMV100 Adenovirus viral load BK polyomavirus rMV084 BK polyomavirus viral load Cytomegalovirus (CMV) rMV001 CMV-IgG rMV002 CMV-IgM rMV018 CMV-infected cell Ag* rMV041 CMV-viral load rMV042 CMV-DNA (qualitative) rMV094 QuantiFERON-CMV Dengue virus rMV079 Dengue IgG/IgM/NS1 (Rapid) rMV004 Dengue IgG/IgM (Rapid) rMV068 Dengue IgG (ELISA) rMV092 Dengue IgM (ELISA) rMV080 Dengue-RNA (qualitative) Epstein-Barr virus (EBV) rMV005 EBV-IgG rMV006 EBV-IgM rMV029 EBV-IgA rMV051 EBV(EBNA)-IgG rMV066 EBV-viral load Hepatitis B virus rMV037 HBV-viral load
VIROLOGY
Hepatitis C virus MERS - Coronavirus rMV038 HCV-RNA (qualitative) rMV085 MERS-CoV (RT-PCR)* rMV039 HCV-viral load rMV086 MERS-CoV & Respiratory virus 19 subtypes* rMV065 HCV genotype (Linear array) rMV087 MERS-CoV & Influenza A/B/RSV(RT-PCR)* Hepatitis E virus Mumps virus rMV101 Hepatitis E virus (RT-PCR) rMV070 Mumps-IgG rMV071 Mumps-IgM Herpes simplex virus (HSV) Norovirus rMV007 HSV-IgG rMV008 HSV-IgM rMV096 Norovirus Ag (Rapid) rMV017 HSV-infected cell Ag rMV103 Norovirus (RT-PCR) rMV020 HSV isolation* Parainfluenza virus rMV052 HSV-DNA (qualitative) rMV058 Parainfluenza 1, 2, 3 Ag rMV102 Tzanck smear rMV062 Parainfluenza 1,2,3 isolation* Human papilloma virus (HPV) Parvovirus rMV055 HPV-16/18 & high risk types rMV025 Parvo B19 IgG rMV026 Parvo B19 IgM Human immunodeficiency virus (HIV) Respiratory syncytial virus (RSV) rMV034 HIV-DNA (qualitative) rMV093 Influenza A,B,RSV Ag (Rapid) rMV035 HIV-viral load rMV053 RSV isolation* rMV098 Antiretroviral resistance analysis Rotavirus (RT & Protease) rMV016 Rotavirus Ag (Rapid) Influenza virus Rubella virus rMV093 Influenza A,B,RSV Ag (Rapid) rMV010 Rubella-IgG rMV011 Rubella-IgM rMV081 Influenza A/B/RSV (RT-PCR) Varicella-zoster virus (VZV) rMV061 Influenza (A,B) isolation* rMV030 VZV-IgG rMV031 VZV-IgM rMV064 Influenza A (H5N1)* rMV069 VZV-DNA (qualitative) rMV088 Influenza A (H7N9)* rMV072 VZV-infected cell Ag JC polyomavirus rMV102 Tzanck smear rMV099 JC polyomavirus viral load Zika virus Measles virus rMV089 Zika virus (RT-PCR) rMV032 Measles-IgG rMV033 Measles-IgM rMV090 Zika virus-IgG rMV091 Zika virus-IgM Multiple viruses rMV078 Rotavirus and Enteric adenovirus (Rapid) rMV081 Influenza A/B/RSV (RT-PCR) rMV095 Multiplex mosquito borne viruses [Dengue virus type 1-4, Zika virus, and Chikungunya virus] rMV012 TORCH-IgG [Rubella, CMV, HSV] rMV013 TORCH-IgM [Rubella, CMV, HSV] rMV083 Herpesvirus 1-8 and Enterovirus (Microarray) [HSV-1,2, VZV, EBV, CMV, HHV-6,7,8, and Enterovirus] rMV056 Respiratory virus Ag (Panel 7 types) [Influenza A,B; Parainfluenza 1,2,3; Adenovirus; RSV] rMV060 Respiratory virus isolation (Panel 7 types)* [Influenza A, B; Parainfluenza 1,2,3; Adenovirus; RSV] rMV082 Respiratory virus 19 subtypes (Microarray) [Adenovirus; Bocavirus; Coronavirus 229E, HKU1, NL63, OC43; hMPV; Influenza A (H1, H3, H1N12009); Influenza B; Parainfluenza 1, 2, 3, 4; RSV A, B; Enterovirus/Rhinovirus] rMV097 Gastroenteritis panel (Microarray) คาแนะนาในการเก็บตัวอย่างส่งตรวจ -- กรุณาดูรายละเอียดในคู่มือสิ่งส่งตรวจ --
*กรุณาติดต่อห้องปฏิบัติการทุกครั้งก่อนส่งตรวจ รายการตรวจ อื่นๆ โปรด พลิก
