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Patient Data Collection Form

This patient data collection form contains information about a patient's medical history, physical examination findings, lab investigations, diagnoses, treatment and progress. It includes demographic details, social and family histories, past medical issues, medications, surgeries, presenting complaints, physical exam parameters, blood work results for complete blood count, liver and kidney function tests, electrolytes, lipid profiles, blood sugars, urine analysis and microbiology cultures if needed. Treatment details like medications, adherence and outcomes are also noted. The form is used to comprehensively document all relevant clinical information about a patient during their hospital stay or clinic visit.

Uploaded by

VINAY KUMAR
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1K views8 pages

Patient Data Collection Form

This patient data collection form contains information about a patient's medical history, physical examination findings, lab investigations, diagnoses, treatment and progress. It includes demographic details, social and family histories, past medical issues, medications, surgeries, presenting complaints, physical exam parameters, blood work results for complete blood count, liver and kidney function tests, electrolytes, lipid profiles, blood sugars, urine analysis and microbiology cultures if needed. Treatment details like medications, adherence and outcomes are also noted. The form is used to comprehensively document all relevant clinical information about a patient during their hospital stay or clinic visit.

Uploaded by

VINAY KUMAR
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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PATIENT DATA COLLECTION FORM

Patient Demographic Details:


IPNO:
AGE/GENDER:
DOA:
DOD:
DEPARTMENT:
SOCIAL HISTORY:
FAMILY HISTORY:
PAST MEDICAL HISTORY:

PAST MEDICATION HISTORY:

SURGICAL HISTORY:

PRESENTING COMPLAINTS:

DIAGNOSIS:
PHYSICAL EXAMINATION:

PARAMETER NORMAL DAYS OF TREATMENT


RANGE 1 2 3 4 5 6 7 8
BP 120/80mm/H
g
PR 60-100b/min
HR 60-100b/min
RR 12-16b/min
SPO2 95-100%

LAB INVESTIGATIONS:
COMPLETE BLOOD PICTURE:
PARAMETER NORMAL RANGE D-1 D-2 D-3 D-4 D-5 D-6 D-7 D-8
S
Hb M-14-18g/dl
F-12-16g/dl
PCV M-38.3-48.6%
F-35.5-44.9%
RBC M-4.7-
6.1mcells/mcl
F-4.2-5.4
TLC 4000-
11000cells/cumm
N 45-75%
L 20-40%
E 1-6%
B 0-1%
M 1-8%
PLATELET 1-3 lakhs/cmm
ESR M<10, F<20
mm/hr
MCV 76-96fl
MCH 27-32
MCHC 30-35%

LIVERFUNCTION TEST:
PARAMETERS NORMAL D-1 D-2 D-3 D-4 D-5 D-6
RANGE
TOTAL BILIRUBIN 0-1mg/dl
DIRECT 0-
BILIRUBIN 0.35mg/dl
INDIRECT 0.2-
BILIRUBIN 0.65mg/dl
SGOT 5-40IU/L
SGPT 5-40IU/L
ALKALINE 25-140U/L
PHOSPHATASE
TOTAL PROTEINS 6.4-
8.2G/dl
ALBUMIN 3.4-
5.0G/dl
GLOBULIN 1.5-
3.5G/dl
A/G RATIO

RENAL FUNCTION TESTS:


PARAMETERS NORMAL D-1 D-2 D-3 D-4 D-5 D-6
RANGE
BLOOD 10-
UREA 50mg/dl
SR. 0.8-
CREATININ 1.2mg/dl
E
URIC ACID F-2.4-
6mg/dl
M-3.4-
7mg/dl
BUN 7-
20mg/dL
ELECTROLYTES:
PARAMETERS NORMAL D-1 D-2 D-3 D-4 D-5 D-6
RANGE
SODIUM 135-
148mEq/L
POTASSIUM 3.5-
5.3mEq/L
CHLORIDE 98-
106mmol/
L
CALCIUM 8.5-
10.3mg/dL
PHOSPHORUS 2.8-
4.5mg/Dl

COMPLETE URINE EXAMINATION:


PARAMETER NORMAL RANGE RESULT
COLOUR YELLOW
APPEARANCE CLEAR
SPECIFIC GRAVITY 1.005-1.030g/ml
REACTION 4.5 -8
ALBUMIN Negative
KETONE BODIES Neagtive
SUGAR Negative
BLOOD Negative
URINOBILINOGEN 0.2-1.0
RBC Nil/hpf
WBC Nil/hpf
CASTS Absent
CRYSTALS Absent
EPITHELIAL CELLS 1-2/hpf
PUS CELLS 1-2/hpf

LIPID PROFILE:
PARAMETERS NORMAL D-1 D-2 D-3 D-4 D-5 D-6
RANGE
TOT.CHOLESTERO <200mg/D
L l
HDL >40-
60mg/dL
LDL 70-
130mg/dL
VLDL <2-
30mg/dL
TRIGLYCERIDES 10-
150mg/dL
CHOL/HDL 5/1

BLOOD SUGAR LEVELS: GRBS:


PARAMETER NORMAL RANGE RESULT
RBS 79-160mg/dl
FBS 90-110mg/dl
PPBS <140mg/dl
HBA1C 4.5-6.4%
OTHER LAB INVESTIGATIONS:

PRINCIPAL DIAGNOSIS:

FINAL DIAGNOSIS:

DRUG CHART
S.N DRUG GENERI DOSE/FRE RO CATEGORY DAYS OF
O NAM C NAME Q A TREATMENT
E
DAY WISE COMPLAINTS CHART

DATE COMPLAINT
MEDICATION ADHERENCE SCORE:

DRUG INTERACTIONS:

ADR:

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