DATA COLLECTION FORM

COMPARATIVE PROSPECTIVE STUDY BETWEEN SINGLE METRONIDAZOLE REGIMEN AND COMBINATION OF

METRONIDAZOLE WITH LACTOBACILLUS FOR TREATMET OF BACTERIAL VAGINOSIS.

PATIENT NAME: I.P. NO.:

AGE(yrs.): WEIGHT(kgs): SEX: UNIT:

COMPLAINTS ON ADMISSION:

MEDICAL HISTORY:

MEDICATION HISTORY:

SOCIAL HISTORY:

FAMILY HISTORY:

PHYSICAL EXAMINATION: CULTURE TESTS:

BACTERIAL ORGANISM DETECTED:
GRAM +VE:
GRAM VE:

DIAGNOSTIC TESTS:

URINE ANALYSIS:
AMSELS CRITERIA:
CLUE CELLS 1 2 3
EPI CELL:
WBC
RBC
 PROGRESS NOTES
DRUG TREATMENT CHART
VISITS
CURRENT DRUGS DOSE ROUTE FREQ. 1 2 3 4 5

STUDENT SIG: DR.USHA SURESH SIG:

(MD; D.G.O)