Alkem

Patient No *

Patient Initials *

Date of Enrollment *

Investigator *

Site *

Age (in Years) *

Gender *

Male Female

Occupation

Weight (in Kg) *

Height (in cm) *

Presenting complaints *

Current medical diagnosis *

Comorbidities *

Previous surgeries or interventions *

PULSE (Bpm)

BP (mmhg)

Pallor

Yes No

Icterus

Yes No

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

Yes No

Hemoglobin level

Platelet count

Renal function parameters (Serum Creatinine, BUN, etc)

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

Any Other (Please specify )

Brand Name*

Generic Name *

Dosage *

Frequency *

Duration *

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

Yes No

Indication for Gastroprotective Agent Use *

Prophylactic Control of Active gastrointestinal bleeding Any other

Demographics