===== CLINICAL RECORD FORM FOR SNAKE BITE =====

|**CLINICAL REPORT FORM…………………………………………………** |Code:…………………………………..|……………………………………….|

|Date:|…………………………..|Time:|…………………………..|…………………………………|……………………………….|…………………………….|

|Calling doctor|……………………………………….|Hospital Place|……………………………………….|Phone:|…………………………………………|

|Patient Name|………………………………………………………………….|Contact Number ……………………………………………………………….|

|DOB:|……………………………………………|Age:|………………………………………|Sex: M / F|UR no.|…………………………………………….|

|Animal ID……….|Snake……….|spider……….|marine……….|other……….|unsure………..|not seen………..|……………………………………….|

|Date of Bite|………………………………|Time of Bite:|…………………………..|Location at time of bite:|……………………………………………..|

|Body Part Bitten|…………………………………………..|No of Bites|…………..|First Aid & Timing|……………………………………………………|

|**SYMPTOMS:** |………………………………………………………………………………………………………………………………………………………..|

|**SIGNS:** |……………………………………………………………………………………………………………………………………………………………….|

|**LAB:** |…………………………….|……………………………..|SVDK:|Not done…….|neg…….|pos…….|T………|B………|M……..|D………|T……..|

|**TREATMENT:** |………………………………………………………………………………………………………………………………………………………|

|**RECOMMENDATIONS:** |………………………………………………………………………………………………………………………………………….|

|Date|………………….|………………….|………………….|…………………..|…………………..|………………….|…………………..|………………….|

|Time|………………….|………………….|………………….|…………………..|…………………..|………………….|…………………..|………………….|

|**TREATMENT** |……………………………………………………………………………………………………………………………………………………….|

|Antivenom|…………………….|……………………|…………………….|…………………….|……………………|…………………….|……………………|

|Other Rx|…………………….|…………………….|……………………..|……………………..|…………………….|…………………….|………………….|

|**LAB DATA** |

|PT/INR|…………………|………………….|…………………..|………………….|…………………..|………………….|………………….|…………………|

|aPTT|………………….|………………….|………………….|…………………..|…………………..|…………………..|…………………..|…………………|

|Fibrinogen|………………….|…………………|………………….|…………………|………………….|…………………|………………….|…………………|

|XDP/FDP|…………………|………………….|…………………|………………….|………………….|………………….|…………………|………………….|

|Platelets|………………….|………………….|………………….|………………….|………………….|…………………|………………….|…………………|

|CK|………………….|…………………..|…………………..|……………………|……………………|…………………..|………………….|………………….|

|K<sup>+</sup>  |…………………..|…………………..|…………………..|…………………..|…………………..|…………………..|…………………..|………………….|

|Creatinine|………………….|…………………|………………….|…………………|………………….|…………………|………………….|………………….|

|Urea|……………….|………………..|………………..|…………………|………………..|………………..|……………….|………………|

|WCC|………………….|…………………..|…………………..|…………………..|…………………..|………………….|…………………|………………….|

|Lymph|………………….|…………………..|…………………..|………………….|…………………..|…………………..|…………………|………………..|

|Hb|………………….|…………………..|……………………|……………………|…………………..|…………………..|…………………..|…………………|

|LDH|………………….|……………………|…………………..|……………………|………………….|……………………|…………………|…………………|

|AST|…………………..|…………………..|……………………|…………………..|………………….|………………….|………………….|………………….|

|Other:|…………………|…………………..|…………………..|…………………..|…………………..|…………………|………………….|………………….|

\\