Checkup Form

Checkup Date

SBP

DBP

DVRT

NVRT

NVLT

CV

Fundoscopy

Urine Albumin

Urine Suagr

Urine Biles

Urine Kitones

Urine Pus Cells

Urine Epithelial

Hb%

WBC

R B C

P C V

M C V

M C H

M C H C

Neutrophils

Lymphocytes

Eosinophils

Monocytes

Basophils

Platelets

E S R

RBS

Blood Urea

Sr. Creatinine

Uric Acid

Total Cholesterol

HDL

LDL

Triglycerides

Total Bilirubin

Direct Bilirubin

Indirect Bilirubin

SGOT

SGPT

ALP

FVC

FEV1

FEV1/FVC

FEF 25-75

PFT Result

Chest X-ray

ECG

HBsAg

Widal Test

Mantoux Test

Notes

AC Rt 500 Hz

AC Rt 1000 Hz

AC Rt 2000 Hz

AC Rt 500 Hz

AC Rt 1000 Hz

AC Rt 2000 Hz

AC Rt 500 Hz

AC Rt 1000 Hz

AC Rt 2000 Hz

AC Rt 4000 Hz

AC Rt 8000 Hz

AC Lt 500 Hz

AC Lt 1000 Hz

AC Lt 2000 Hz

AC Lt 4000 Hz

AC Lt 8000 Hz

BC Rt 500 Hz

BC Rt 1000 Hz

BC Rt 2000 Hz

BC Rt 4000 Hz

BC Rt 8000 Hz

BC Lt 500 Hz

BC Lt 1000 Hz

BC Lt 2000 Hz

BC Lt 4000 Hz

BC Lt 8000 Hz

Audiometry Result

ECHO

Ultrasound

PAP Smear/PSA

Mammogram

Vitamin B12

Vitamin D

HbA1C

Bone Density

CT Scan

MRI

Other Tests

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