Registry Data Form

Personnel Details Clinical History Injury Details Injury Examination Blood Investigations ECG Investigations CT Brain Systemic Radiology Pre-hospital Care Management Emergency Conservative Management Surgical Management Diagnosis and Outcome Outcome at Discharge Follow Up

Demographics Details

First Name:

Last Name:

Age: Age in years.

Gender:

Street/Village/City:

PIN Code:

State:

Country:

Contact Number:

Email:

Informant:

Mode of Arrival:

Education Level:

Occupation:

Income Group:

Marital Status:

Handedness:

Spoken Language(s):

Food Preference:

Sleep Pattern Description:

Diagnosis and Outcome

ICD-10:

ICD-10 Other:

ECG

Date of ECG:

Time of ECG:

ECG 12 Leads

ECG Results:

Rhythm:

Conduction:

Conduction Other:

QRS ST Complex:

QRS ST Complex Other:

QT Interval:

ECG Impression:

Echocardiography

Ejection Fraction:

Regional Wall Motion Abnormality:

ECG

Date of ECG:

Time of ECG:

ECG 12 Leads

ECG Results:

Rhythm:

Conduction:

Conduction Other:

QRS ST Complex:

QRS ST Complex Other:

QT Interval:

ECG Impression:

Echocardiography

Ejection Fraction:

Regional Wall Motion Abnormality:

Follow Up

Disability Eye Opening (Discharge):

Disability Eye Opening (3 Months):

Disability Eye Opening (6 Months):

Disability Communication (Discharge):

Disability Communication (3 Months):

Disability Communication (6 Months):

Disability Motor Response (Discharge):

Disability Motor Response (3 Months):

Disability Motor Response (6 Months):

Disability Feeding (Discharge):

Disability Feeding (3 Months):

Disability Feeding (6 Months):

Disability Toileting (Discharge):

Disability Toileting (3 Months):

Disability Toileting (6 Months):

Disability Grooming (Discharge):

Disability Grooming (3 Months):

Disability Grooming (6 Months):

Disability Level Functioning (Discharge):

Disability Level Functioning (3 Months):

Disability Level Functioning (6 Months):

Disability Employability (Discharge):

Disability Employability (3 Months):

Disability Employability (6 Months):

Follow Up

Disability Eye Opening (Discharge):

Disability Eye Opening (3 Months):

Disability Eye Opening (6 Months):

Disability Communication (Discharge):

Disability Communication (3 Months):

Disability Communication (6 Months):

Disability Motor Response (Discharge):

Disability Motor Response (3 Months):

Disability Motor Response (6 Months):

Disability Feeding (Discharge):

Disability Feeding (3 Months):

Disability Feeding (6 Months):

Disability Toileting (Discharge):

Disability Toileting (3 Months):

Disability Toileting (6 Months):

Disability Grooming (Discharge):

Disability Grooming (3 Months):

Disability Grooming (6 Months):

Disability Level Functioning (Discharge):

Disability Level Functioning (3 Months):

Disability Level Functioning (6 Months):

Disability Employability (Discharge):

Disability Employability (3 Months):

Disability Employability (6 Months):

Injury Details

Date of Injury:

Time of Injury:

Injury Duration:

History of Major Injury

History of Major Injury Specify:

Mass Casuality

Mass Casuality Specify:

Time Elapsed Hospital Admission:

Reason For Delay:

Reason For Delay Other:

Air Bag

Seat Belt

Driving License

Helmet Use

Helmet Fastening

Helmet Make:

Cause of Injury:

Cause of Injury Other:

Type of Vehicle:

Vehicle Crash Pattern:

Incident Victim:

Incident Victim Other:

Dominant Type of Injury:

Dominant Type of Injury Other:

Mechanism of Injury:

Injury Details

Date of Injury:

Time of Injury:

Injury Duration:

History of Major Injury

History of Major Injury Specify:

Mass Casuality

Mass Casuality Specify:

Time Elapsed Hospital Admission:

Reason For Delay:

Reason For Delay Other:

Air Bag

Seat Belt

Driving License

Helmet Use

Helmet Fastening

Helmet Make:

Cause of Injury:

Cause of Injury Other:

Type of Vehicle:

Vehicle Crash Pattern:

Incident Victim:

Incident Victim Other:

Dominant Type of Injury:

Dominant Type of Injury Other:

Mechanism of Injury:

Emergency Management

Arrival Time ER:

Left Time ER:

Time To ER:

Time In ER:

Date of Admission:

Time of Admission:

Date of Discharge:

Hospital Stay:

Attempt To Control Bleeding

Method Used To Control Bleeding:

Basic Life Support Given

Brought Dead

Pre-hospital Cardiac Arrest

Prehospital Airway Management

Fluids At Scene

Activation Of Trauma Team

Trauma Team Activated:

Airway:

Breathing:

Circulation:

Airway Management:

Discharge Destination ER:

Discharge Destination ER Other:

Disposition From Emergency:

Disposition From Emergency Other:

Outcome at Discharge

Survival Status at Discharge:

Discharge Destination (Hospital):

Discharge Destination (Hospital) Other:

Outcome at Discharge

Survival Status at Discharge:

Discharge Destination (Hospital):

Discharge Destination (Hospital) Other:

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Registry Data Form

Registry Data Form

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