Form LAB0416 "Parasitology Lab Report Form" - California

What Is Form LAB0416?

This is a legal form that was released by the California Department of Public Health - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2011;
  • The latest edition provided by the California Department of Public Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form LAB0416 by clicking the link below or browse more documents and templates provided by the California Department of Public Health.

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Download Form LAB0416 "Parasitology Lab Report Form" - California

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Patient
CA State Department of Public Health, Microbial Diseases Laboratory
PARASITOLOGY Lab 0416(rev 5/2011)
850 Marina Bay Parkway, Richmond, CA 94804 (510-412-3700)
State Laboratory Specimen Number:
Patient name: Last
First
Middle Initial
Age or DOB
Sex
Physician Name:
Address:
Hospital:
Phone number
Return Report To:
Symptoms, travel, treatment:
Name:
Address:
Specimen source:
Collection date:
City, State, Zip Code
Submitter’s Result:
Test requested:  Routine O&P
 Malaria
 Cryptosporidia
 Cyclospora
 Microsporidia
 Other ____________________________________________________________________________________________
Fecal parasites:
(Routine O&P)
No parasites detected (Trichrome Stain & Ritchie Concentration)
Positive for:
Entamoeba histolytica/dispar group
 Ascaris lumbricoides
Blastocystis hominis
 Clonorchis / Opisthorchis
Dientamoeba fragilis
Chilomastix mesnili
 Diphylobothrium spp.
Giardia lamblia
Endolimax nana
(Trichrome, EIA or FA)
 Enterobius vermicularis
Iodoamoeba butschlii
 Hookworm
Entamoeba coli
 Hymenolepis nana
Entamoeba hartmanni
 Paragonimus spp.
Entamoeba polecki
 Strongyloides stercoralis
 Taenia spp.
 Trichuris trichura
Cyclospora cayetanensis  negative
 positive by:  autofluorescence  modified Kinyoun stain
Cryptosporidia spp.
 negative
 positive by:  modified Kinyoun stain  EIA  FA
Microsporidia .
 negative
 positive by:  modified Trichrome stain
Other Parasite:
_________________________________  detected  not detected
method:________________________________________
Malaria:
 No malarial parasites detected
 Positive for:
 Plasmodium vivax
 Plasmodium ovale
 Plasmodium malariae
Plasmodium falciparum
Forms, if present, are so indicated
__________rings
__________growing trophs
__________mature trophs
__________immature schizonts
___________mature schizonts
__________gametocytes
__________microgametes
RBC appearance________________________________________
__________Schnuffner’s stippling
 Plasmodium species, unable to identify further due to ______________________________________________________________________
Other results / comments:
Date reported
Patient
CA State Department of Public Health, Microbial Diseases Laboratory
PARASITOLOGY Lab 0416(rev 5/2011)
850 Marina Bay Parkway, Richmond, CA 94804 (510-412-3700)
State Laboratory Specimen Number:
Patient name: Last
First
Middle Initial
Age or DOB
Sex
Physician Name:
Address:
Hospital:
Phone number
Return Report To:
Symptoms, travel, treatment:
Name:
Address:
Specimen source:
Collection date:
City, State, Zip Code
Submitter’s Result:
Test requested:  Routine O&P
 Malaria
 Cryptosporidia
 Cyclospora
 Microsporidia
 Other ____________________________________________________________________________________________
Fecal parasites:
(Routine O&P)
No parasites detected (Trichrome Stain & Ritchie Concentration)
Positive for:
Entamoeba histolytica/dispar group
 Ascaris lumbricoides
Blastocystis hominis
 Clonorchis / Opisthorchis
Dientamoeba fragilis
Chilomastix mesnili
 Diphylobothrium spp.
Giardia lamblia
Endolimax nana
(Trichrome, EIA or FA)
 Enterobius vermicularis
Iodoamoeba butschlii
 Hookworm
Entamoeba coli
 Hymenolepis nana
Entamoeba hartmanni
 Paragonimus spp.
Entamoeba polecki
 Strongyloides stercoralis
 Taenia spp.
 Trichuris trichura
Cyclospora cayetanensis  negative
 positive by:  autofluorescence  modified Kinyoun stain
Cryptosporidia spp.
 negative
 positive by:  modified Kinyoun stain  EIA  FA
Microsporidia .
 negative
 positive by:  modified Trichrome stain
Other Parasite:
_________________________________  detected  not detected
method:________________________________________
Malaria:
 No malarial parasites detected
 Positive for:
 Plasmodium vivax
 Plasmodium ovale
 Plasmodium malariae
Plasmodium falciparum
Forms, if present, are so indicated
__________rings
__________growing trophs
__________mature trophs
__________immature schizonts
___________mature schizonts
__________gametocytes
__________microgametes
RBC appearance________________________________________
__________Schnuffner’s stippling
 Plasmodium species, unable to identify further due to ______________________________________________________________________
Other results / comments:
Date reported