Establishment of Population Based Stroke Registry in Ludhiana
(ICMR TASK FORCE PROJECT)
Questionnaire 1  : Hospital and OPD Patients


 
Subject Identification Number  
Date of registration    
Source of Data    
Patient individual details
Patient's Full Name/Initials (Use CAPITALS, include all names)  
Contact phone number  
Postal address  
Demopgraphic characteristics of patient
Date of birth    
If date of birth unknown, enter AGE in years  
Sex  
Marital status  
Religion  
Resident of Ludhiana  
Duration of residence(in months)  
Education
What is the highest level of education the person has completed?  
     
Occupation:
Which of the following best describes the main work status of the person over the last 12 months?  
     
Information on acute stroke event
Date of stroke (symptoms onset, or first noticed on)    
Presenting symptoms
     
Which side of the body was affected?  
Limb weakness  
Loss of sensation  
Aphasia/dysphasia  
Double vision  
Unsteady gait  
Dizziness  
Headache  
Dysarthria  
Seizures  
Loss of consciousness  
Facial Wakness  
Deviation of Mouth  
What type of stroke was diagnosed?  
How was the diagnosis of stroke type verified?  
Vascular risk factors
Which of the following vascular risk factors is the patient know to have?
Atrial fibrillation  
Diabetes mellitus  
Hypertension  
Carotid stenosis  
Previous TIA  
Rheumatic Heart Disease  
Coronary arteey disease  
Drug Addiction  
Tobacco(Current use)  
Tobacco(Past)  
Hyperlipidemia  
Alcohol (Current use)  
Alcohol (Past)  
Pregnancy/Postpartum  
Desi Ghee Intake  
Neuroinfections
Outcome  
If alive at discharge, Modified Rankin scale