Loss consciousness duration: --------- Less than one minute Less than 30 minutes Less than an hour 1-24 hours 1-7 days More than 7 days

Vomiting: --------- Yes No

Nausea: --------- Yes No

Ear bleed: --------- Yes No

Nasal bleed: --------- Yes No

Oral bleed: --------- Yes No

Headache: --------- Yes No

Seizures: --------- Yes No

Seizures duration:

Rhinorrhea: --------- Yes No

Otorrhoea: --------- Yes No

Post traumatic amnesia: --------- Yes No

Post traumatic amnesia duration: --------- PTA less than 5 minutes PTA between 5-60 minutes PTA between 1-24 hours PTA between 1-7 days PTA greater than 7 days

Lucid interval: --------- Yes No

Diabetes: --------- Yes No

Hypertension: --------- Yes No

Smoking: --------- Yes No

Tobacco smokeless: --------- Yes No

Illicit drug use: --------- Yes No

Anti platelet agents: --------- Yes No

Asprin: --------- Yes No

Clopidogrel: --------- Yes No

Oral contraceptives: --------- Yes No

Sedatives: --------- Yes No

Anticonvulsants: --------- Yes No

Other history:

Influence alcohol: --------- Yes No

Breath analyzer test: --------- Yes No

Blood alcohol levels:

Influence drug: --------- Yes No

ASA PS: --------- ASA-PS 1. A normal healthy patient ASA-PS 2. A patient with mild systemic disease ASA-PS 3. A patient with severe systemic disease ASA-PS 4. A patient with severe systemic disease that is a constant threat to life ASA-PS 5. A moribund patient who is not expected to survive without an operation ASA-PS 6. A declared brain-dead patient whose organs are being removed for donor purposes Unknown

Date injury:

Time injury:

Injury duration:

History any major injury last 12 months: --------- Yes No

Mass causality more than 10 persons: --------- Yes No

Time elapsed injury to hospital admission: --------- < 24 hours 24 - 72 hours 4 - 7 days > 7 days

Reason delay admission: --------- Delayed in ED Transfer from other hospital Distance to hospital from place of injury No transport facility Sought traditional treatment Other please specify

Air bag: --------- Yes No

Seat belt: --------- Yes No

Driving license: --------- Yes No

Helmet use: --------- Yes No

Helmet fastening: --------- Yes No

Helmet make: --------- ISI Non-ISI

Cause injury: --------- Road Traffic accident Ship accident Airplane crash Train accident Assault Hanging Fall of object Crush Sports Others please specify

Vehicle type: --------- Bicycle Animal cart Four wheeler car Four wheeler bus Four wheeler truck Motorized two wheeler Three wheeler

Vehicle crash pattern: --------- Vehicle skidded Hit a non-moving object Fall from vehicle Collision with animal/others

Incident victim: --------- Pillion rider Back seat passenger Front seat passenger Pedestrian Others (please specify)

Dominant type injury: --------- Abrasion Amputation Blast injury Blunt Bruise Burn Contusion Crush injury Cut Dislocation Drowning Fracture limbs Laceration Penetrating injury Sprain Penetrating injury gunshot Penetrating injury stab Self - fall / Self hit on wall or door Others(please specify)

Mechanism injury: --------- Animal related injury Bicycle Accident Electrocution Fall from bed Fall from Height/Building /Train/Bus Heavy substance fall on head Hit by Train Lightening Motor Vehicle Trauma: Ejected Motor Vehicle Trauma: not ejected Pedestrians Penetrating injury gunshot Penetrating injury stab Road traffic accident Self-fall/Self hit on wall or door Three wheeler Two wheeler Unknown

External bleeding: --------- Yes No

Body regions abdomen: --------- Yes No

Body regions cervical spine: --------- Yes No

Body regions chest: --------- Yes No

Body regions face: --------- Yes No

Body regions head: --------- Yes No

Body regions lower limbs: --------- Yes No

Body regions lumbar spine: --------- Yes No

Body regions neck: --------- Yes No

Body regions pelvic cavity: --------- Yes No

Body regions pelvic girdle: --------- Yes No

Body regions thorax: --------- Yes No

Body regions thoracic spine: --------- Yes No

Body regions upper limbs: --------- Yes No

Body regions genitalia: --------- Yes No

Body regions others please specify:{{ form.body_regions_others_please_specify}}

{{ form.any_life_threatening_injuries_airway_obstruction.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_tension_pneumothorax.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_open_pneumothorax.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_massive_haemothorax.label_tag }} --------- Yes No

Any life threatening injuries flail chest:{{ form.any_life_threatening_injuries_flail_chest}}

{{ form.any_life_threatening_injuries_cardiac_tamponade.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_simple_pneumo_haemothorax.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_aortic_rupture.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_tracheobronchial_rupture.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_pulmonary_contusion.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_blunt_cardiac_injury.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_blunt_splenic_injury.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_diaphragmatic_rupture.label_tag }} --------- Yes No

{{ form.any_life_threatening_injuries_others_please_specify.label_tag }}

Abbreviated injury scale head neck:{{ form.abbreviated_injury_scale_head_neck}}

Abbreviated injury scale brain injury:{{ form.abbreviated_injury_scale_brain_injury}}

Abbreviated injury scale cervical spine:{{ form.abbreviated_injury_scale_cervical_spine}}

Abbreviated injury scale external skin:{{ form.abbreviated_injury_scale_external_skin}}

Abbreviated injury scale face: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Abbreviated injury scale thorax chest: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Abbreviated injury scale thoracic spine: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Abbreviated injury scale abdomen: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Abbreviated injury scale pelvis: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Abbreviated injury scale lumbar spine: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Abbreviated injury scale extremities: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Abbreviated injury scale pelvic girdle: --------- Minor Injury Moderate Injury Serious Injury Severe Injury Critical Injury Maximum Injury

Hemoglobin:

Total leucocyte count:{{ form.total_leucocyte_count}}

Blood sugar random:{{ form.blood_sugar_random}}

Blood sugar fasting:{{ form.blood_sugar_fasting}}

Blood sugar pp:

Hematocrit:

Platelets:

Blood group:

Sodium:

Potassium:

Creatinine:

Bun:

Ph:

Hco3:

Pco2:

Po2:

Arterial base excess:{{ form.arterial_base_excess}}

Lactate:

Urine pregnancy test:{{ form.urine_pregnancy_test}}

Prothrombin time:{{ form.prothrombin_time}}

Inr:

Troponin c:

Date ecg:

Time ecg:

Ecg 12 leads: --------- Yes No

Ecg results: --------- Normal Abnormal

Ecg rhythm: --------- Normal sinus Sinus arrhythmia Atrial fibrillation Atrial flutter Premature ventricular contraction Other arrhythmias

Ecg conduction: --------- Normal LBBB RBBB AV block Others (Please specify)

Qrs st complex: --------- Normal Non-specific ST changes Old MI Myocardial ischemia Acute myocardial infarction Others (Please specify)

Qt interval:

Ecg impression:

Echocardiography:{{ form.echocardiography}}

Ejection fraction:{{ form.ejection_fraction}}

Regional wall motion abnormality:{{ form.regional_wall_motion_abnormality}}

Fast:

Chest x ray:

Cervical spine x ray:{{ form.cervical_spine_x_ray}}

Dorsal spine x ray:{{ form.dorsal_spine_x_ray}}

Lumbar spine x ray:{{ form.lumbar_spine_x_ray}}

Pelvis x ray:

Long bone x rays:{{ form.long_bone_x_rays}}

Ct cervical spine:{{ form.ct_cervical_spine}}

Ct chest:

Ct abdomen:

Ct pelvis:

Mri brain:

Mri spine:

Dsa:

Date ct:

Time ct:

Contrast: --------- Yes No

Extradural hemorrhage:{{ form.extradural_hemorrhage}}

Acute subdural hemorrhage:{{ form.acute_subdural_hemorrhage}}

Chronic subdural hemorrhage:{{ form.chronic_subdural_hemorrhage}}

Intracerebral hemorrhage:{{ form.intracerebral_hemorrhage}}

Cerebral contusion:{{ form.cerebral_contusion}}

Subarachnoid hemorrhage:{{ form.subarachnoid_hemorrhage}}

Intraventricular hemorrhage:{{ form.intraventricular_hemorrhage}}

Skull fracture: --------- Yes No

Extradural hemorrhage location:{{ form.extradural_hemorrhage_location}}

Acute subdural hemorrhage location:{{ form.acute_subdural_hemorrhage_location}}

Chronic subdural hemorrhage location:{{ form.chronic_subdural_hemorrhage_location}}

Intracerebral hemorrhage location:{{ form.intracerebral_hemorrhage_location}}

Cerebral contusion location:{{ form.cerebral_contusion_location}}

Extradural hemorrhage side:{{ form.extradural_hemorrhage_side}}

Acute subdural hemorrhage side:{{ form.acute_subdural_hemorrhage_side}}

Chronic subdural hemorrhage side:{{ form.chronic_subdural_hemorrhage_side}}

Intracerebral hemorrhage side:{{ form.intracerebral_hemorrhage_side}}

Cerebral contusion side:{{ form.cerebral_contusion_side}}

Subarachnoid hemorrhage side:{{ form.subarachnoid_hemorrhage_side}}

Asdh volume:

Edh volume:

Ich volume:

Skull fracture type:{{ form.skull_fracture_type}}

Skull fracture location:{{ form.skull_fracture_location}}

Subarachnoid hemorrhages:{{ form.subarachnoid_hemorrhages}}

Mass effect pressure:{{ form.mass_effect_pressure}}

Hydrocephalus: --------- Yes No

Parenchymal lesions small shearing:{{ form.parenchymal_lesions_small_shearing}}

Third ventricular compression:{{ form.third_ventricular_compression}}

Contralateral ventricle dilated:{{ form.contralateral_ventricle_dilated}}

Any herniation: --------- Yes No

Cerebral ischemia:{{ form.cerebral_ischemia}}

Penetrating missile tract:{{ form.penetrating_missile_tract}}

Air sinus involved:{{ form.air_sinus_involved}}

Intracranial air:{{ form.intracranial_air}}

Midline shift: --------- Yes No

Obliteration of the third ventricle:{{ form.obliteration_of_the_third_ventricle}}

Petechial hemorrhages:{{ form.petechial_hemorrhages}}

Midline shift mm:{{ form.midline_shift_mm}}

Basal cisterns: --------- Normal Compressed Absent

Ct classification category:{{ form.ct_classification_category}}

Fischers grade: --------- I. No blood detected II. Diffuse thin (<1 mm) SAH with no clots III. Localized clots and/or layers of blood >1 mm in thickness IV. Intracerebral or intraventricular blood (+/- SAH)

Pre hospital care:{{ form.pre_hospital_care}}

Resuscitation: --------- Yes No

Arrive from injury site:{{ form.arrive_from_injury_site}}

Protective equipment transfer:{{ form.protective_equipment_transfer}}

Highest level pre hospital care:{{ form.highest_level_pre_hospital_care}}

Highest level in hospital care:{{ form.highest_level_in_hospital_care}}

Mortality: --------- Died at Scene Brought Dead Operation Theatre Alive at admission

Arrival time er:

Left time er:

Time to er:

Time in er:

Date admission:

Time admission:

Date discharge:

Hospital stay:

Attempt to control bleeding:{{ form.attempt_to_control_bleeding}}

Method used to control bleeding:{{ form.method_used_to_control_bleeding}}

Basic life support given:{{ form.basic_life_support_given}}

Brought dead: --------- Yes No

Pre hospital cardiac arrest:{{ form.pre_hospital_cardiac_arrest}}

Prehospital airway management:{{ form.prehospital_airway_management}}

Fluids at scene or on way to hospital:{{ form.fluids_at_scene_or_on_way_to_hospital}}

Activation trauma team:{{ form.activation_trauma_team}}

Airway: --------- Clear Obstructed Adjunctive airway Intubated

Breathing: --------- Spontaneous, adequate Spontaneous, insufficient Manual support with bag, valve, mask Mechanical ventilation

Circulation no specific treatment:{{ form.circulation_no_specific_treatment}}

Circulation iv fluids:{{ form.circulation_iv_fluids}}

Circulation crystalloids:{{ form.circulation_crystalloids}}

Circulation hypertonic saline:{{ form.circulation_hypertonic_saline}}

Circulation colloids:{{ form.circulation_colloids}}

Circulation blood:{{ form.circulation_blood}}

Circulation vasopressors:{{ form.circulation_vasopressors}}

Circulation cpr: --------- Yes No

Airway management:{{ form.airway_management}}

Discharge destination from er:{{ form.discharge_destination_from_er}}

Disposition from emergency:{{ form.disposition_from_emergency}}

Bed rest: --------- Yes No

Blood transfusion:{{ form.blood_transfusion}}

Central line: --------- Yes No

Cervical collar: --------- Yes No

Cervical traction:{{ form.cervical_traction}}

Chest tube: --------- Yes No

Colloid: --------- Yes No

Crystalloid: --------- Yes No

Hyperventilation therapy:{{ form.hyperventilation_therapy}}

Hypothermia therapy:{{ form.hypothermia_therapy}}

Intubation: --------- Yes No

Mannitol: --------- Yes No

Nasogastric tube:{{ form.nasogastric_tube}}

Nutrition replacement:{{ form.nutrition_replacement}}

Seizure prophylaxis:{{ form.seizure_prophylaxis}}

Steroids: --------- Yes No

Tetanus toxoid: --------- Yes No

Urinary catheter:{{ form.urinary_catheter}}

Ventilation: --------- Yes No

Days ventilator: --------- Yes No

Date surgery:

Icp monitoring: --------- Yes No

Intracranial surgery:{{ form.intracranial_surgery}}

Extracranial surgery:{{ form.extracranial_surgery}}

Any re surgery: --------- Yes No

Cranial surgical intervention acute sdh:{{ form.cranial_surgical_intervention_acute_sdh}}

Cranial surgical intervention contusion:{{ form.cranial_surgical_intervention_contusion}}

{{ form.cranial_surgical_intervention_craniofacial_surgery.label_tag }} --------- Yes No

Cranial surgical intervention csf shunt:{{ form.cranial_surgical_intervention_csf_shunt}}

Cranial surgical intervention chronic sdh:{{ form.cranial_surgical_intervention_chronic_sdh}}

{{ form.cranial_surgical_intervention_decompressivecraniectomy.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_depressed_skull_fracture.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_epidural_hematoma.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_intracerebral_hematoma.label_tag }} --------- Yes No

Cranial surgical intervention infection:{{ form.cranial_surgical_intervention_infection}}

{{ form.cranial_surgical_intervention_optic_nerve_decompression.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_posterior_fossa_surgery.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_external_ventricular_drainage.label_tag }}{{ form.cranial_surgical_intervention_external_ventricular_drainage}}

{{ form.cranial_surgical_intervention_wound_debridement.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_foreign_body_removal.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_bone_flap_replacement.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_cranioplasty.label_tag }} --------- Yes No

{{ form.cranial_surgical_intervention_others_please_specify.label_tag }}

{{ form.extracranial_surg_interven_maxillofacial_intervention.label_tag }} --------- Yes No

{{ form.extracranial_surg_interven_lower_limb_fracture_internal_fixation.label_tag }}{{ form.extracranial_surg_interven_lower_limb_fracture_internal_fixation}}

{{ form.extracranial_surg_interven_lower_limb_fracture_external_fixation.label_tag }}{{ form.extracranial_surg_interven_lower_limb_fracture_external_fixation}}

{{ form.extracranial_surg_interven_upper_limb_fracture_internal_fixation.label_tag }}{{ form.extracranial_surg_interven_upper_limb_fracture_internal_fixation}}

{{ form.extracranial_surg_interven_upper_limb_fracture_external_fixation.label_tag }}{{ form.extracranial_surg_interven_upper_limb_fracture_external_fixation}}

Extracranial surg interven laparotomy:{{ form.extracranial_surg_interven_laparotomy}}

{{ form.extracranial_surg_interven_pelvic_fracture_internal_fixation.label_tag }}{{ form.extracranial_surg_interven_pelvic_fracture_internal_fixation}}

{{ form.extracranial_surg_interven_pelvic_fracture_external_fixation.label_tag }}{{ form.extracranial_surg_interven_pelvic_fracture_external_fixation}}

{{ form.extracranial_surg_interven_spinal_stabilization_cervical.label_tag }} --------- Yes No

{{ form.extracranial_surg_interven_spinal_stabilization_thoracic.label_tag }} --------- Yes No

{{ form.extracranial_surg_interven_spinal_stabilization_lumbar.label_tag }} --------- Yes No

Extracranial surg interven thoracotomy:{{ form.extracranial_surg_interven_thoracotomy}}

{{ form.extracranial_surg_interven_tracheostomy_in_er.label_tag }} --------- Yes No

{{ form.extracranial_surg_interven_tracheostomy_in_icu.label_tag }} --------- Yes No

{{ form.extracranial_surg_interven_others_please_specify.label_tag }}

Complications hypotension episode:{{ form.complications_hypotension_episode}}

Complications hypoxia episode:{{ form.complications_hypoxia_episode}}

Complications infections:{{ form.complications_infections}}

Complications deep vein thrombosis:{{ form.complications_deep_vein_thrombosis}}

{{ form.complications_other_organ_damage_secondary_to_brain_injury.label_tag }}{{ form.complications_other_organ_damage_secondary_to_brain_injury}}

Complications others please specify:{{ form.complications_others_please_specify}}

Final diagnosis icd 10:{{ form.final_diagnosis_icd_10}}

Survival status at discharge:{{ form.survival_status_at_discharge}}

Discharge destination:{{ form.discharge_destination}}

Disability rating scale discharge:{{ form.disability_rating_scale_discharge}}

{{ form.disability_rating_scale_a_eye_opening_discharge.label_tag }} --------- 0-Spontaneous 1-To Speech 2-To Pain 2-To Pain 3-None

{{ form.disability_rating_scale_b_communication_ability_discharge.label_tag }}{{ form.disability_rating_scale_b_communication_ability_discharge}}

{{ form.disability_rating_scale_c_motor_response_discharge.label_tag }} --------- 0-Obeying 1-Localizing 2-Withdrawing 3-Flexing 4-Extending 5-None

{{ form.disability_rating_scale_d_feeding_discharge.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_e_toileting_discharge.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_f_grooming_discharge.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_g_level_of_functioning_discharge.label_tag }} --------- 0-Completely Independent 1-Independent in special environment 2-Mildly Dependent-Limited assistance (non-resid - helper) 3-Moderately Dependent-moderate assist (person in home) markedly 4-Dependent-assist all major activities, all times 5-Totally dependent-24 hour nursing care

{{ form.disability_rating_scale_h_employability_discharge.label_tag }} --------- 0-Not Restricted 1-Selected jobs, competitive 2-Sheltered workshop, Non-competitive 3-Not Employable

Disability rating scale three months:{{ form.disability_rating_scale_three_months}}

{{ form.disability_rating_scale_a_eye_opening_three_months.label_tag }} --------- 0-Spontaneous 1-To Speech 2-To Pain 2-To Pain 3-None

{{ form.disability_rating_scale_b_communication_ability_three_months.label_tag }}{{ form.disability_rating_scale_b_communication_ability_three_months}}

{{ form.disability_rating_scale_c_motor_response_three_months.label_tag }} --------- 0-Obeying 1-Localizing 2-Withdrawing 3-Flexing 4-Extending 5-None

{{ form.disability_rating_scale_d_feeding_three_months.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_e_toileting_three_months.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_f_grooming_three_months.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_g_level_of_functioning_three_months.label_tag }}{{ form.disability_rating_scale_g_level_of_functioning_three_months}}

{{ form.disability_rating_scale_h_employability_three_months.label_tag }} --------- 0-Not Restricted 1-Selected jobs, competitive 2-Sheltered workshop, Non-competitive 3-Not Employable

Disability rating scale six months:{{ form.disability_rating_scale_six_months}}

{{ form.disability_rating_scale_a_eye_opening_six_months.label_tag }} --------- 0-Spontaneous 1-To Speech 2-To Pain 2-To Pain 3-None

{{ form.disability_rating_scale_b_communication_ability_six_months.label_tag }}{{ form.disability_rating_scale_b_communication_ability_six_months}}

{{ form.disability_rating_scale_c_motor_response_six_months.label_tag }} --------- 0-Obeying 1-Localizing 2-Withdrawing 3-Flexing 4-Extending 5-None

{{ form.disability_rating_scale_d_feeding_six_months.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_e_toileting_six_months.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_f_grooming_six_months.label_tag }} --------- 0-Complete 1-Partial 2-Minimal 3-None

{{ form.disability_rating_scale_g_level_of_functioning_six_months.label_tag }}{{ form.disability_rating_scale_g_level_of_functioning_six_months}}

{{ form.disability_rating_scale_h_employability_six_months.label_tag }} --------- 0-Not Restricted 1-Selected jobs, competitive 2-Sheltered workshop, Non-competitive 3-Not Employable