DATA COLLECTION FORM

DATE: / /2014

1. IDENTIFICATION

1.1 ID CODE:

1.2 NAME :

1.4 SEX: Male Female 1.5 DATE OF BIRTH: / /

1.6 RELIGION: Muslim Hindu Others

2. BIOPHYSICAL CHARACTERISTICS

2.1 AGE: 2.2 WEIGHT: KGs 2.3 PULSE:2.4 TEMPERATURE: 2.5 HEIGHT:

3. PERSONAL HISTORY

3.1 AREA OF RESIDENCE: (Tick Mark as follows

3.2 IMPRESSION ABOUT SOCIAL CLASS: (Tick Mark as follows

3.3 Personal and Social HistoryPlease provide the following information (circle yes or no and provide the details indicated):

Personal HistoryTobacco:Have you ever smoked? Yes NoIf yes, for how many years?

Number of packs per day?

If yes, do you still smoke? Yes NoIf no, when did you quit? DateBlood Products:Have you had blood, blood products, or globulin exposure/transfusions?

Yes No

If yes, when? Type of product:If yes, reason for transfusionAlcohol:Do you currently drink alcohol? Yes NoNumber of drinks per day__________ Number of days per week___________ Type__________________Street Drugs:Have you ever used drugs? (cocaine, marijuana, uppers, downers, LSD, etc.)

Yes No

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Rural Urban S-urban Others

Rich Upper Middle Lower Middle

Poor

Destitute

Have you ever inhaled drugs? Yes NoHave you ever used IV needles? (non-medical injections) Yes No

3.4. Psychiatric HistoryCondition Yes NoHave you ever been diagnosed with depression? Yes NoHave you ever been treated for depression? Yes NoHave you ever been hospitalized for a psychiatric illness? Yes NoDo you describe yourself as anxious? (at times or consistently?) Yes NoHave you ever been diagnosed with any other psychiatric disease?

Yes No

3.5. Family HistoryAny family member with liver disease? No/Yes, _______________

4. SIGNS & SYMPTOMS: Early signs of liver damage

SIGNS & SYMPTOMS TICK MARK

TIME

JuandiceNauseaLoss of appetiteFatigueDiarrheaBleeding easilySwollen abdomenMental disorientation or confusionSleepinessComaFeverVomitingOthers

5.Have you been Vaccinated for the followings

Hepatitis A Yes NoHepatitis B Yes NoHepatitis C Yes No

Pneumovax (Pneumonia Yes No

6. TYPES OF LIVER DISEASE

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NO TYPES TIME1 Liver Cirrhosis2 Liver Cancer3 Hepatitis4 Wilson disease5 Gilbert's

syndrome67

7. TYPES OF DRUG:

Medications Brand Name

Amount/Size

frequency (how many/day)

Water & Electrolyte replacement/ Saline/ LIBOTT-1000ml

Drugs for nausea, vomiting & vertigo/Metoclopramide hydrochloride 10mg

MOTILON

Drugs for peptic ulcer/ Proton pump inhibitor /Antacids

Losectel/ Seclo/Omeprazole

Drugs for emetics/Domperidone Tab. OmidonSpironolactone Tab. UrsocalTab. ZincatDrugs for hypertension /Frusemide & Spironolactone

Tab. Edeloss

Drugs for constipation/lactulose (5ml)/ Syp. D- LacDrugs for neurodegenerative diseases/Procyclidine hydrochloride 5mg CYCLID 5

Vitamin, mineral & nutritional drug MedigoldAnalgesic & Antipyretic & NSAIDsSedative

8. ALLERGIESDo you have any reaction/ allergies to medicines? Yes NoIf yes, List the following:

Medication Reaction

9. Have you ever had a Liver biopsy: Yes No If yes gives date(s ……………………………If yes, What did it show? (Score/description/ fibrosis, etc ……………………………………………………………………….

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10. LIVER FUNCTION TESTPARAMETERS RESULT REFERENCE REMARKS

S. Bilirubin 2-21 umol/L or, Adults: Upto 1.1mg/dl;New born: Upto 12.0 mg/dl

Creatinin 0.5-1.3mg/dlSGPT Upto 40 U/LSHPT/ALT Upto 42 U/LAlkaline Phosphates Adult: 20-130; Child: 60-270S. Albumin 3.8-5.1 g/dl

11. ELECTROLYTESTest Result REFERENCE

Sodium 135-148 mmol/LPotassium 3.5-5.5 mmol/LChloride 95-107 mmol/LTCO2 23-30 (Ad, 18-24 (Ch

12. HAEMATOLOGY REPORTTest Name Result Normal value

ESR: Westergren Method 0-10mm/1st HourHaemoglobin Male:15±2gm/dl; Female:

13.5±1.3gm/dlRBC Male: 5±0.5x10ˆ12/L

Female: 4.3±0.5x10ˆ12/LPlatelate 150-400x10ˆ9/LWBC 7±3x10ˆ9/L

13. ENDOSCOPY REPORTFINDINGSOesophagus

Stomach

Duodenum

14. ULTRASONOGRAPHY REPORTTypes Nor

malAbnormal

Liver

Gall bladder

CBD & biliary channels

Pancreas

Spleen

Both the kidneys

Urinary bladder

4

Prostate

Impression

15. Report on the Analysis of Copper in Urine

Color of urine :

Concentration of Cu (g/ L : (Concentration above 100 g/ 24h (1.6mol/24h confirm Wilson’s disease)

INVESTIGATED BY

NAME: Md. Waliullah Wali

SIGNATURE:DATE: / / 2014

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