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1.Screening
1.1.Inclusion Criteria

Inclusion criteria

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1.2.Exclusion Criteria

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刘义彬

Date

2021-11-11 yyyy-mm-dd

2.Baseline
2.1.Medical History

120 小时

Average times of menstrual onset a year

10 次/年

Average menstrual cycle

36.5 天(days)

Menarche time

13 岁(years)

The time of last Menstruation

2021-10-22 年、月、日(yyyy-mm-dd)

The time of menstrual onset before the last one

不详 年、月、日(yyyy-mm-dd)

Disease or surgery name

Date of the confirmation or the surgery

-- 年/月/日(yyyy-mm-dd)

Date

2021-11-11 yyyy-mm-dd

2.2.General information

Date of signing the informed consent

2021-11-11

Date of birth

1996-11-02 yyyy-mm-dd

Age

25 Years

Education background

University

Occupation

Other

Other (Description)

自由职业

2.3.Physical examination

Vulva

Not examined

Description in detail for abnormal

Vagina

Not examined

Description in detail for abnormal

Uterine neck

Not examined

Description in detail for abnormal

Corpus uteri

Not examined

Description in detail for abnormal

Adnexa uteri

Left side

Not examined

Description in detail for abnormal

Right side

Not examined

Description in detail for abnormal

Weight

117.5 kg

Hight

172 mm

Systolic pressure (SP)

115 mmHg

Diastolic pressure

83 mmHg

Temperature

36 degree Celsius

Pulse rate

101 次/分

Breath frequency

25 次/分

Doctor signature

刘义彬

Date

2021-11-11 yyyy-mm-dd

2.4.Blood Routine Tests

WBC

×109 /L

NEUT%

%

LY%

%

MONO%

RBC

×10^12 /L

HGB

g/L

PLT

×10^9 /L

Researcher signature

Date

yyyy-mm-dd

2.5.Urine Routine Test

Acidity and allkalinity

pH value

Urine protein

Urine red cell

Urine WBC

Urine glucos

Urine Bilirubin

Urine HCG

KET

SG

UBG

NIT

Date of test

yyyy-mm-dd

2.6.Blood Biochemical items Tests

ALT

U/L

AST

U/L

GGT/γ-GT

U/L

ALP

U/L

TBIL

μmol/L

DBIL

μmol/L

IBIL

μmol/L

ALB

g/L

UA

umol/L

UREA

mmol/L

Cr

umol/L

TC

mmol/L

TG

mmol/L

HDL

mmol/L

LDL

mmol/L

CK

U/L

CK-MB

U/L

LDH

U/L

K

mmol/L

Na

mmol/L

Cl

mmol/L

Ca

mmol/L

Glu

mmol/L

Date

yyyy-mm-dd

2.7.Coagulation Function Tests

Prothrombin time

Thrombin time (TT)

Activated partial thromboplastin time (APTT)

Fibrinogen (FIB)

g/L

Date of examination

yyyy-mm-dd

2.8.HBV/HCV/HIV/Syphilis Markers Test

HBV

HCV

Date of test

yyyy-mm-dd

2.9.Blood Gas Analysis

PCO2

mmHg

PH

SBE

mmol/l

HCO3

mmol/l

SO2

P02

mmHg

LAC

mmol/L

Date of examination

(yyyy-mm-dd)

2.10.D-dimer Test

2.11.HCG Test

mIU/mL

Urine HCG

2.12.Visual Analogue Scale

Pain Visual Analogue Score

2.13.Image Examinations

cm*cm*cm

cm

cm

Date of examination

yyyy-mm-dd

Abdomen CT examination

Description in detail for abnormal

Date of examination

yyyy-mm-dd

2.14.Other Tests
3.In the process of the treatment
3.1.Treatment Record

cm

°

4.Follow-up
4.1.Physical examination

BG Puncture site

Temperature

Systolic pressure (SP)

mmHg

Diastolic pressure (DP)

mmHg

Heart Rate, HR

次/分

Blood pressure

mmHg

4.2.Blood Routine Test

WBC

×109 /L

NEUT%

%

LY%

%

RBC

×10^12 /L

MONO%

HGB

g/L

PLT

×10^9 /L

Date

yyyy-mm-dd

4.3.D-dimer test

D-dimer

D-dimer

Date of test

yyyy-mm-dd

4.4.Visual Analogue Scale

Pain Visual Analogue Score

5.Management system of participants

sample collection

Volume

ml

Time of collection

yyyy-mm-dd-hh-min.

Label Number of the sample

6.ADR/ADE management system

Is there any adverse event?

Severity

Within 30 minites or not?

Begin time at

年/月/日(yyyy-mm-dd)

Time of stop

年/月/日(yyyy-mm-dd)