preview

Patient Socio-Demographic Profile

Satisfactory Essays
Open Document

APPENDIXES:
Appendix 1
CASE RECORD FORM:
Patient’s Socio-demographic profile:
S. No:

Name:

Age:

Sex (male/female):

Central Registration No:

Date of admission:

Date of examination:

Mobile No:

Level of education:

Occupation (Govt. employee/self-employed/student):

Marital status (married/unmarried):

Address:

Patient’s Clinical profile:
Chief complaints:

Clinical Diagnosis:

Past Illness:
• Diabetes Mellitus:
• Hypertension:
• COPD:
• Bronchial Asthma:
• CAD:
• CVA:
• H/O Delirium:
• Dementia:
• Depression:
Personal:
• Alcohol intake:
 Units of alcohol per day:
 Frequency of intake:
 Alcohol product used:
 CAGE question score:
• Smoking habit:
 Product used for smoking:
 No. per day:
 Smoking index: …show more content…

Orientation:
 Time (present/absent):
 Place (present/absent):
 Person( present/absent): ii. MMSE score (Appendix 5):
• Glasgow Coma Scale:
• Auditory impairment:
• Vision impairment:
• Coordination:
 Finger-Nose-Finger Test:
 Rapid alternating movement:
• Gait (normal/abnormal):
• RASS (Appendix 4):
• CAM-ICU score (Appendix 3):
• DRS-98 Score (Appendix 6): Patient’s status:

Patient’s Laboratory investigation profile:
Hematological:
• Hemoglobin (gm/dl):
• Total Leukocyte Count (per mm3):
• Platelet (x 103/mm3):
• Hematocrit (%): Value:
Biochemical:
• Sodium (mmol/L):
• Potassium (mmol/L):
• Urea (mg/dl):
• Creatinine (mg/dl):
• BUN : Creatinine ratio:
• Bilirubin (Total) (mg/dl):
• AST (U/L):
• ALT (U/L):
• ALP (U/L):
• Protein (Total) (gm/dl):
• Albumin (gm/dl):
• Calcium (mg/dl):
• Magnesium (mg/dl):
• Amylase (U/L):
• Triglyceride (mg/dl):
• Cholesterol (mg/dl):
• Random Blood Sugar (mg/dl):
• TSH (uIU/dl): Value:
Microbiological:
• Blood Culture:
• Urine Culture:
• Body Fluid Culture:
Urine:
• Pus cell (cells/hpf):
• RBC (present/absent):
• Sugar (present/absent):
• Albumin (present/absent):
ABG:
• pH:
• PO2 (mm Hg):
• PCO2

Get Access
Related
Get Access