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:

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---------
Male
Female

Street/Village/City:

PIN Code:

State:

Country:

Contact Number:

Email:

Informant:

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---------
Patient Himself
Bystander

Mode of Arrival:

---------

---------
Self
Private Vehicle
Ambulance/108 staff
Police/Firefighters
Rescuers
Bystanders/Neighbours
Relatives
Others (Please specify)

Education Level:

---------

---------
Profession or Honours
Graduate or Postgraduate
Intermediate or post high school diploma
High school certificate
Middle school certificate
Primary school certificate
Illiterate

Occupation:

---------

---------
Legislators, senior officials, and managers
Professionals
Technicians and associate professionals
Clerks
Skilled workers and shop and market sales workers
Skilled agricultural and fishery workers
Craft and related trade workers
Plant and machine operators and assemblers
Elementary occupation
Unemployed

Income Group:

---------

---------
>20,482
10,241-20,481
7681-10,240
5120-7680
3072-5119
1034-3071
<1033

Marital Status:

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---------
Married
Never married
Divorced

Handedness:

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---------
Right
Left
Ambidextrous

Spoken Language(s):

Food Preference:

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Vegetarian
Non-Vegetarian
Vegan

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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