Bharati Regimen Patients data submission form

Name of Pt:

Address :

 Tel No :      Reg.No:  

  Gravida        Para      SpontAbortion     Induced Abortion   Live Children

  Scar Over Uterus      LMP Date     Gest age in wks.

 Past Medical Problem

 Zero Hr Date    Zero Hr Time

 Onset of Symptoms on Time scale and Intensity  (Time not to scale after 72 hrs)

                    0Hr      Pain In Abdomen/ Cramps   P     Intensity   +  ++   +++  Stopped  P0

                                    Nausea and Vomiting          V      Intensity   +  ++   +++  Stopped  V0     

                    24 Hr       Spotting                              S     Intensity   +   ++    +++ Stopped  S0

                                       Bleeding                            B     Intensity   +   ++    +++ Stopped   B0

              48 Hr           Fainting/Giddiness             F      Intensity   +  ++    +++ Stopped   F0

                                                  Misoprost Tab    200 microgram Orally        M             

                 72 Hr                         Admission to Hospital      A 

                 4 Day                        D&C                                     C

             7  Day                        Discharge from Hospital     D

             10 Day                      USG                                         U 

                 14 Day  

    Next Period Date             Contraception advised

 Patients Attitude :

Total rejection/ Very  unsatisfied    unsatisfied   Happy       Very happy 

Will recommend  to other friends        Will choose same procedure if again required 

Knowledge about this treatment  

 From News paper          From friends         From Doctors 

  Total Expense     Rupees           

  Doctor Code    Unit Code