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CRF Form

The document is a case report form from the National Institute of Unani Medicine, detailing a study on the effects of Munḍij wa Mus’hil-e-Balgham on urine characteristics and lipid profiles in dyslipidemia cases. It includes sections for patient demographics, medical history, personal and socioeconomic history, general physical examination, and vital signs. The form is structured to collect comprehensive data for clinical evaluation and research purposes.

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9 views3 pages

CRF Form

The document is a case report form from the National Institute of Unani Medicine, detailing a study on the effects of Munḍij wa Mus’hil-e-Balgham on urine characteristics and lipid profiles in dyslipidemia cases. It includes sections for patient demographics, medical history, personal and socioeconomic history, general physical examination, and vital signs. The form is structured to collect comprehensive data for clinical evaluation and research purposes.

Uploaded by

muneebaharoon.99
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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National Institute Of Unani Medicine

An autonomous body under the Ministry of AYUSH, Govt. of India


Kottigepalya, Magadi Main Road, Bangalore – 560091

CASE REPORT FORM

The effect of Munḍij wa Mus’hil-e-Balgham on Urine Characteristics, and Lipid Profile


in Cases of Dyslipidemia

Case No._____________ C.R. No._______________ OPD/IPD Reg. No._____________

Name of the Patient_________________________________ Age/ Gender____________

Father’s/ Spouse Name______________________________________

Address__________________________________________________________________________________

________________________________________________________

Phone No._____________________________ Occupation__________________________

Marital status □ Unmarried □ Married □ Widow □ Separated

Religion □ Islam □ Hindu □Christian □ any other,

specify_____________

Date of involvement in study_______________ Date of Completion of study___________

Height (in meters) _______________ Weight (in kilograms) ________________

BMI ________________________

Present complaint
__________________________________________________________________________________________

__________________________________________________________________________________________

____________________________________________________________________________________
Any past History

H/O Diabetes ___________ H/O Hypertension _________ H/O any chronic

disease________

Any bleeding diathesis_________________________________________________________________

Any drug allergy_________________________

Any diet intake 8-10 hours before procedure_____________________________

Family history________________________________________________________________________

LMP (if applicable) ______________________________

Any unani/ allopathic medicine currently in use_______________________________________

Personal history/ Socioeconomic History:

Diet: □ Veg □ non-veg □ Mixed

Appetite: □ Good □ Average □ Poor

Bowel: □ Clear □ Diarrhea □ Constipated

Bladder: □ Free □ Polyuria □ Dysuria □ Dribbling □Burning

Sleep: □ Sound □ Disturbed □ Increased

Lifestyle: □ Sedentary □ Average □ Laborer

Addiction: □ Tea □ Coffee □ Alcohol □ Pan chewing □ Tobacco □

smoking

□ No addiction

GENERAL PHYSICAL EXAMINATION:

1. General Appearance: …………………….

2. Built (Average/Thin/Overweight/Obese/Dwarf/Tall Stature): ………………………………


3. Pallor/ Icterus / Cyanosis …………………. 4. Edema: Local/General: ………………

5. Lymphadenopathy …………………………

6. Eye: …………………………………… 7. Face: …………………….

8. Examination of Extremities …………………

9. Others: …………………….

10. Temperament of Patient (Damwi / Balghami / Safrawi / Sauda): …………………….

Vitals:

Pulse: ……………………/minute Blood Pressure: ……………………mmHg

Temperature: ……………………ᵒF Respiratory rate: ……………………/minute

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