Patient name and date of birth (address) Urinary Stone Analysis Center Bonn harnsteinanalysezentrum bonn Prof. Dr. rer. nat. A. Hesse * Dr. med. R. M. Schaefer Dr. med. Ph. Lossin * Prof. Dr. med. D. Bach Theaterplatz 14, D - 53177 Bonn - Bad Godesberg Phone: +49 228 95737 16 * Fax: +49 228 95737 21 Sender/Stamp/Date To fill in by the SENDER: Type of stone: urinary stone other* yes no Recurrence: Date of stone passage dd.mm.yy Sample received on: Sample-No.: Result in weight-% Stone removal spontaneous operative conservative chemolitholytic instrumental lithotryptic kidney right kidney left ureter right ureter left bladder urethra yes no Localization Core-Shell-Analysis Stone Lab *Additional comments: overall core Whewellite Weddellite Carbonatapatite (Dahllite) Brushite Struvite Uric acid (Uricit) Uric acid dihydrate Ammonium urate Cystine No. of stones/ gravel Stone colour white yellow black brown =1 =2 =3 =4 Stone surface green = 5 beige = 6 grey = 7 rough =1 smooth = 2 bizarre = 3 Date/Signature: stone analysis by infrared-spectroscopy stone analysis by infrared-spectroscopy shell
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