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Case Record Form

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.

Uploaded by

Roh Jiten
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
564 views

Case Record Form

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.

Uploaded by

Roh Jiten
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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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