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Patients who replies "No" to any of the above questions will not enter the study | |
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3. Ages between 18~65 years old | |
|
Date | yyyy-mm-dd |
|
Doctor's signature |
|
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1. Patients with either II-degree debrided burn wound or donor site | |
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Patients who replies "Yes" to any of the above questions will not enter the study | |
|
Doctor's signature |
|
|
Date | yyyy-mm-dd |
|
Other diseases | |
|
If yes, please describe |
|
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History of allergic disease | |
|
If yes, please describe |
|
|
If yes, please describe |
|
|
If yes, please describe |
|
|
Date | yyyy-mm-dd |
|
Doctor's signature |
|
|
Name of Drug |
|
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Date of birth | yyyy-mm-dd |
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Education level | |
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Start Date |
|
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Systolic pressure (SP) | mmHg |
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End Date |
|
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Diastolic pressure (DP) | mmHg |
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Dosage per Day |
|
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Respiratory rate | 次/分 |
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Grouping | |
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Route of Administration |
|
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Pulse rate | 次/分 |
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Marital status |
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Wound Bed (erythema) | |
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Signs and Symptoms | |
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Wound Location |
|
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Wound Surface Area | cm2 |
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Wound Bed (bleeding) | |
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Wound Bed (exudation) | |
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Wound Type |
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Uric acid | μmol/L |
|
Creatinine | μmol/L |
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Urea nitrogen | mmol/L |
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Serum albumin | g/L |
|
Serum bilirubin | μmol/L |
|
AST | U/L |
|
ALT | U/L |
|
Urine protein | g/L （或定性） |
|
Urine red cell | 个/μL （或定性） |
|
Urine WBC | 个/μL （或定性） |
|
PLT | X10*9/L |
|
Hb | g/L |
|
RBC | X10^12/L |
|
WBC | X10*9/L |
|
Routine Urinalysis | |
|
Routine Blood Test | |
|
Date of test |
|
|
Date of examination | yyyy-mm-dd |
|
Liver Function Test | |
|
Date of test | yyyy-mm-dd |
|
Renal Function Test | |
|
Date of test | yyyy-mm-dd |