Study Proforma
Tamil Nadu Accident and Emergency Care Initiative
Madras Medical College – Rajiv Gandhi Government General Hospital
“Clinical Evaluation of a Portable Near-Infrared Device for Detection of Traumatic Intracranial Hematomas” - Study Proforma
Study Number 02112018
Section 1 : Patient Details
Serial Number
Name of the Patient *
Gender of the Patient *
Age of the Patient
Date of Admission *
MM
/
DD
/
YYYY
Time of Admission *
Time
:
Open Injury *
CT Findings
Date of CT Scan *
MM
/
DD
/
YYYY
Time of CT Scan *
Time
:
Location of the Hematoma *
Required
Plane of the Hematoma *
Age of the Hematoma *
CT Findings as Written in Case Sheet *
Required
Scanner Measurements (4 Parameters) to be entered by the Examiner
Frontal Measurements *
Temporal Measurements *
Parietal Measurements *
Occipital Measurements *
Examiner Details
Name of the Examiner *
Category of the Examiner *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service