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  • Case Record Form

    Uploaded by

    Roh Jiten
    33 views1 page
    This document contains a case record form for collecting patient information including name, age, contact details, health history, lifestyle habits like opium and tobacco use, physical measurements, medical test results, and space for follow up notes. The form aims to gather comprehensive health and lifestyle data on patients in a standardized format.

    Original Description:

    iec for research

    Original Title

    IEC_p11

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    This document contains a case record form for collecting patient information including name, age, contact details, health history, lifestyle habits like opium and tobacco use, physical measurements, medical test results, and space for follow up notes. The form aims to gather comprehensive health and lifestyle data on patients in a standardized format.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    33 views1 page

    Case Record Form

    Uploaded by

    Roh Jiten
    This document contains a case record form for collecting patient information including name, age, contact details, health history, lifestyle habits like opium and tobacco use, physical measurements, medical test results, and space for follow up notes. The form aims to gather comprehensive health and lifestyle data on patients in a standardized format.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 1

    Caserecordform

    Name
    Age
    Phone

    Address
    Sex
    IP no/Volunteer no
    Consent signed
    Sample Date/ collected at/
    processed at
    Sample no / Archive coordinate
    Takes opium? What form? How
    much ?

    When started opium / How long ?

    Smokes Bidi ? How much ? How


    long
    Comorbidities & other
    coaddictions and other significant
    history
    Medication history

    Height
    Weight

    BMI

    CIMT

    Plaque and % Block

    Blood Sugar (Fasting/ hours post


    meal ?)
    Total Cholesterol

    Waist circumference

    BP

    Follow up if any

    Miscellaneous Comments

    hsCRP
    Any other investigations

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