FISA PARTICIPANTULUI IN STUDIU

DATE DE PASAPORT

DATE DESPRE SPITALIZARE

Nume, Prenume, Patronimic _______________

Fisa

______________________________________

IMSP ____________ Departament ___________

Data nasterii ___/___/_______ Virsta ____ ani

Spitalizare primara/repetata

Categoria de virsta ____________ ani

Data spitalizarii ___/___/_______

Gen Masc/Fem

Data externarii ___/____/_______

IDNP

Mediu de trai Rural/Urban

medicala

#/anul

_____________/________

_________________________________ Zile-pat preop____ postop ____ TOTAL _____

Date de contact _________________________

Tip tratament RxT/VP/VP+Co/VP+RxT

______________________ Tel. ____________

Data incheierii supravagherii/deces ___________

Persoana de contact ______________________

Follow up _____ luni

ONCOLOGIE

IMAGISTICA

Tumoarea primara _________________________

USG org. inerne

Da/Nu

_________________________________________

Rx torace

Da/Nu

________________________________________

Rx bazin

Da/Nu

Biopsie ________________________ Rezultat +/-

SpondiloRx

Da/Nu

Starea focarului primar operat/neoperat

Scintigrafie

Da/Nu

Tratamente anterioare

CT

Da/Nu

RMN

Da/Nu

Da/Nu

Ch _____________________________________
RxT ____________________________________
ChT_____________________________________
HnT_____________________________________
DATE ANAMNESTICE

DATE SUBIECTIVE

Tip activitate fizic/intelect/pension/disabilit/alta

Dureri nocturne Da/Nu

Analgezie (OMS)

Durata anamnestic pozitiv _____ luni/ani

SVA I_____ puncte

______

Durata rahialgiei ____________

SVA II_____ puncte

______

Perioada non-metastatica ___ luni/ani

SVA III_____ puncte

______

Tare concomitente _______________________

SVA IV_____ puncte

______

_________________________________________

SVA V_____ puncte

______

SVA VI_____ puncte

______

SVA VII_____ puncte

______

ORTOPEDIE
Nivelul fracturii vertebrale _________

Cifoza locala _____ totala ______ pre-trat

Nr segmentelor vertebrale afectate __________

Cifoza locala _____ totala ______ 1 luna

Leziuni secundare:

Cifoza locala _____ totala ______ 3 luni

osoase extraaxiale

Da/Nu

Cifoza locala _____ totala ______ 6 luni

________________________________________
viscerale

Cifoza locala _____ totala ______ 1 an

Da/Nu

Scor Tokuhashi _____ puncte

________________________________________

Prognostic probabil _______

Minus tesut: A___mm B___mm C____mm NP ____ mm pre-trat

Scor SINS ____ puncte

Minus tesut: A___mm B___mm C____mm NP ____ mm 1 luna

Scor Karnofsky ______ %

Minus tesut: A___mm B___mm C____mm NP ____ mm 3 luni

Minus tesut: A___mm B___mm C____mm NP ____ mm 6 luni

Scor Tomita _____ puncte

Minus tesut: A___mm B___mm C____mm NP ____ mm 1 an

NEUROLOGIE

TERMOGRAFIE

Complicatii NEURO

Da/Nu

CT ______ cm2 pre-trat GT______

Dereglari genitosfinct

Da/Nu

CT ______ cm2 1 luna GT______

Scor ASIA __

Scara Harrington _____

CT ______ cm2 3 luni

GT______

CT ______ cm2 6 luni GT______

CT ______ cm2 1 an
CHIRURGIE

GT______

EVALUAREA DISBILITATII

Tip anestezie _________________

ODI ____%

pre-trat

ODI ____%

Nr segmente operate _____

ODI ____% 6 luni

ODI ____% 1 sapt

Tipul de ciment _________ Abord ___________

ODI ____% 3 luni

ODI ____% 1 an

Volum de ciment____ml Durata operatiei___min

Complicatii ______________________________
EVALUAREA SF-36
pre-trat
DS
FF
RF
SG
VT
FS
RE
SM

1 sapt

1 luna

6 luni

3 luni

1 an

1 luna