Alkem

Subject ID *

Subject Initials *

Investigator *

Centre *

Date of Assessment *

Subject Initials *

Age (in Years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Geographical location *

Allergy *

Yes No

Smoking history *

Yes No

Occupation *

Family history *

Patient directly admitted to ICU *

Yes No

Patient shifted from ward to ICU *

Yes No

Patient referred to ICU from other hospital *

Yes No

Patients with ICU infections *

Yes No

Type of infection *

Hospital acquired Community acquired

Chief complaints *

Clinical Diagnosis *

Duration of current illness *

Severity of disease (APACHE II Score)

During admission
During discharge
Both if available

Previous Antibiotic used (if any)

Date of Assessment	Parameters
	PULSE (Bpm)
	BP (mmhg)
	RR (pm)
	TEMPERATURE (ºF)
	SPO2 (%)
	Specify others (if available)

Medications being used for Current Medical Condition *

Generic Name	Brand Name	Class	Dose	Frequency	Route	Duration







Any Specific Changes in treatment regimen (if available)

Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

Date of Assessment	Tests	Results
{{-- --}}	CBC	{{-- --}}
	Hb (gm/dL)
	RBC (millions/cumm)
	WBC (cumm)
	Platelets (cumm)
	CRP (mg/L)
{{-- --}}	LFT	{{-- --}}
	Bilirubin (T/D/I) (mg/dL)
	SGPT (U/L)
	SGOT (U/L)
	ALP (U/L)
	Protein (T/A/G) (g/dL)
{{-- --}}	RFT	{{-- --}}
	S.Cr (mg/dL)
	BUN (mg/dL)
	eGFR (mL/min/1.73m²)
	Specify others (if available)

Microbial culture sensitivity test results (if available)

Any other investigational test data available like any other test to confirm microbiological agent, if available

Overall Assessment *

Cure Improvement Worsening Mortality

Any secondary infections during hospital stay (details if yes)

Relapse of infection (details if yes)

Total Duration of ICU / Hospital Stay *

Adverse events noted due to study medication *

Yes No

ADVERSE EVENT(S)
AE. No	Adverse Event Term	Date of onset (DD/MM/YYYY)	Severity	Action Taken	Treatment given	Relationship with Study Drug	Outcome	Serious Adverse Event
1					Yes No			Yes No
2					Yes No			Yes No
3					Yes No			Yes No
4					Yes No			Yes No
Severity: 1- Mild; 2- Moderate; 3- Severe; +Action Taken: 1- No Change in IP, 2- IP Temporarily Interrupted, 3- IP Permanently Discontinued, 4- Other, specify *If 'Treatment given 'is ticked as 'Yes' then relevant information should be captured on Prior and concomitant Medication Form. Relationship: 1= Related, 2= Not Related ++Outcome: 1 = Resolved, 2= Recovered/ Resolved with Sequelae, 3= Recovering/ Resolving, 4=Not Recovered/ Not Resolved, 5= Fatal/ result in death, 6= Unknown

Prevalence in ICU

ASSESSMENT OF THERAPY PRESCRIBED

DEMOGRAPHICS and ANTHROPOMETRY

MEDICAL AND SURGICAL HISTORY

VITALS (at time of admission, as available)

TREATMENT OF CURRENT MEDICAL ILLNESS

CONCOMITANT DISEASE and MEDICATION*

LABORATORY PARAMETERs (at time of admission, as available)

OUTCOMES

ADVERSE EVENTS