Establishment of Population Based Stroke Registry in Ludhiana
(ICMR TASK FORCE PROJECT)
Form 3 : Stroke patients from scan centres
 
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  
Resident of Ludhiana  
Duration of residence(in months)  
Demopgraphic characteristics of patient
Date of birth    
If date of birth unknown, enter AGE in years  
Sex  
Information on acute stroke event
Date of stroke (symptoms onset, or first noticed on)  
First ever stroke  
What type of stroke was diagnosed?  
How was the diagnosis of stroke type verified?