FEEDBACK FORM

INJECTION AGGaSY
POLYVALENT EQUINE PURIFIED CONCENTRATED LIQUID OF ANTI-GAS GANGRENE SERA 30,000 I.U./ AMPOULE
FORM NO. Date:

Doctor Name: Doctor Speciality: Contact Details:

Name of Hospital:

Patient Name:_____________________________________________ Brief History:______________________________________________ History of Chronic Diseases:

Date of Admission: Date of Discharge:

History of Abdominal Surgery: Yes: History of Diabetes Mellitus: Yes: No: No:

AGE:__________________YEARS SEX MALE FEMALE BODY WEIGHT (KGs)

OCCUPATION

Previous History of Equine Product Administration: Yes: History of Medicinal Allergy: No:

Indication in which AGGaSy was used:

Trauma Chronic wound

Burn

Gas Gangrene

Post Operative Wound

Specify type of Surgery

Details of Indication in which AGGaSy was used:

Diagnostic Evaluation: 1) Cause of infection: 2) Duration of infection: 3) Severity of infection: Present Treatment: 1) Antibiotics (Specify): 3) Amputation: 5) Other-Specify: 2) Debridement: 4) HBOT:

Dose of AGGaSy Used:

Date of AGGaSy administration:_______________ Prophylaxis: 30000 I.U. Skin sensitivity test: Treatment: 150000 I.U. Done Mode of Administration: Intramuscular Intravenous Skin sensitivity test result: Positive Medication given in case of Positive Skin Sensitivity Test: Negative Not Done

Patient Followup on AGGaSy:

No. 1 0 Day (Day of Injection) Doctor Initials:_____________________________
Date:

No. 2

7th Day (1 week of Injection AGGaSy) Doctor Remarks:

Date:

Doctor Initials:______________________________ No. 3 14th Day (2nd week of Injection AGGaSy) Doctor Remarks:
Date:

Doctor Initials:______________________________
No. 4

30th Day (1 month of Injection AGGaSy) Doctor Remarks:

Date:

Doctor Initials:______________________________
Doctor Remark on AGGaSy: Very Good Satisfactory Doctors Notes: Good Non-Satisfactory

Doctors Signature:_____________________________________

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