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HBR

Assessing the Prevalence of High Bleeding Risk (HBR) Patients in India: A Nationwide Database Analysis.

Patient No *

Patient Initials *

Date of Enrollment *

Investigator *

Site *

Baseline Characteristics

Demographics

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Patient Initials *

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Age (in Years) *

Gender *

Male Female

Occupation

Weight (in Kg) *

Height (in cm) *

Clinical History

Presenting complaints *

Current medical diagnosis *

Comorbidities *

Previous surgeries or interventions *

Vitals

PULSE (Bpm)

BP (mmhg)

RR (pm)

Pallor

Yes No

Icterus

Yes No

History of nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid use

Yes No

Laboratory Values (if available)

Hemoglobin level

Platelet count

Renal function parameters(Serum cretinine, BUN, etc)

Liver function parameters (AST, ALT, Albumin, GGT, etc)

Any Other (Please specify )

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Liver function parameters*

AST ALT Albumin GGT

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Does the patient have any one or more than one of the following factors (please tick as many as applicable) *

History of smoking Chronic kidney disease Past History of minor/major bleeding

Please specify the bleeding

Intracranial Gastrointestinal Variceal Hemorrhoids Treatment of Bleeding

Please Specify

Concurrent use of antiplatelet or anticoagulant therapy Liver disease Anemia Thrombocytopenia History of corticosteroid use Requirement of NSAIDs or oral anticoagulants for other illness or any surgery in near future Other bleeding risk factors

Please Specify

Prescription Pattern of Gastroprotective Agents

Proton pump inhibitors (PPIs)

Brand Name

Generic Name*

Dosage *

Frequency *

Duration *

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Any other gastroprotective agent used. If yes, provide details *

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Any other gastroprotective agent used. If yes, provide details *

Yes No

Brand Name

Generic Name *

Dosage *

Frequency *

Duration *

Indication for Gastroprotective Agent Use *

Prophylactic
Control of Active gastrointestinal bleeding
Any other Please Specify

Additional notes if any

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