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Eligible participant has to fullfill all of the following items | / / / / |
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Anyone with one of following items or more should be excluded: | / / / / / / / / |
- General information
- Medical history
- Physical examination
- Blood Routine Tests
- Urine Routine Test
- Blood Electrolytes Tests
- Coagulation Function Tests
- Serum Liver Function Tests
- HBV/HCV/HIV/Syphilis Markers Test
- Renel Function Test
- D-dimer
- hCG Test
- Image Examinations
- Visual Analogue Scale
- Blood Gas Analysis
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Date of signing the informed consent |
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Date of birth | yyyy-mm-dd |
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Age | Years |
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Education background | |
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Occupation | |
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Other (Description) |
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小时 |
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Number of pregnancy | 次 |
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Number of delivery | 次 |
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If has delivery history, select following items | |
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partus maturus | 次 |
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premature delivery | 次 |
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abortion | 次 |
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Last pregnancy | yyyy-mm-dd |
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Average times of menstrual onset a year | 次/年 |
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Average menstrual cycle | 天(days) |
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Menarche time | 岁(years) |
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The time of last Menstruation | 年、月、日(yyyy-mm-dd) |
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The time of menstrual onset before the last one | 年、月、日(yyyy-mm-dd) |
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年/月/日（yyyy-mm-dd） |
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Namy of the drug to be allergied |
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Vulva | |
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Description in detail for abnormal |
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Vagina | |
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Description in detail for abnormal |
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Uterine neck | |
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Description in detail for abnormal |
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Corpus uteri | |
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Description in detail for abnormal |
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Adnexa uteri | |
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Left side | |
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Description in detail for abnormal |
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Right side | |
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Description in detail for abnormal |
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Weight | kg |
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Hight | mm |
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Systolic pressure (SP) | mmHg |
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Diastolic pressure | mmHg |
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Temperature | degree Celsius |
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Pulse rate | 次/分 |
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Breath frequency | 次/分 |
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Doctor signature |
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Date | yyyy-mm-dd |
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WBC | ×109 /L |
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NEUT% | % |
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LY% | % |
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MONO％ | ％ |
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RBC | ×10^12 /L |
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HGB | g/L |
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PLT | ×10^9 /L |
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Researcher signature |
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Date | yyyy-mm-dd |
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Acidity and allkalinity | |
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pH value |
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Urine protein | |
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Urine red cell | |
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Urine WBC | |
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Urine glucos | |
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Urine Bilirubin | |
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Urine HCG | |
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KET | |
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SG |
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UBG | |
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NIT | |
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Date of test | yyyy-mm-dd |
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Date of test | yyyy-mm-dd |
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K | mmol/L |
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Na | mmol/L |
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Cl | mmol/L |
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Ca | mmol/L |
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P | mmol/L |
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Date of examination | yyyy-mm-dd |
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Prothrombin time | 秒 |
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Thrombin time (TT) | 秒 |
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Activated partial thromboplastin time (APTT) | 秒 |
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Fibrinogen (FIB) | g/L |
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ALT | IU/L |
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AST | IU/L |
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GGT | U/L |
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Serum bilirubin | μmol/L |
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Indirect bilirubin | umol/L |
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Direct bilirubin | umol/L |
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Serum albumin | g/L |
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Serum globulin | g/L |
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Serum total protein | g/L |
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Date of test | yyyy-mm-dd |
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Date of test | yyyy-mm-dd |
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Date of test | yyyy-mm-dd |
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Date of test | yyyy-mm-dd |
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Date of test | yyyy-mm-dd |
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SCr | μmol/L |
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Blood urea | mmol/L |
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Blood uric acid | μmol/L |
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Date of test | yyyy-mm-dd |
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D-dimer value | ug/mL |
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Date of test |
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Urine pregnancy test | |
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Blood HCG concentration | mIU/mL |
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Date of test | yyyy-mm-dd |
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Size of the ulcer | cm*cm |
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Uterine echo distribution | |
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Endometrial thickness | mm |
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Left ovary size | cm ×cm |
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Shape of Left ovary | |
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Size of the Ovarian cyst |
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Right ovary size | cm ×cm |
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Shape of right ovary | |
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Size of Ovarian cyst |
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Description of other abnormal findings |
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Diagnosis of the Ultrasound B |
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Doctor signature |
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Date of examination | yyyy-mm-dd |
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Pain Visual Analogue Score |
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PH |
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PCO2 | mmHg |
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P02 | mmHg |
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SO2 | ％ |
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HCO3 | mmol/l |
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SBE | mmol/l |
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LAC | mmol/L |
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Date of examination | (yyyy-mm-dd) |
右卵巢巧囊 |
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7*7*6 cm |
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0 ° |
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| / | |
刘义彬 |
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2024-1-19 |
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D-dimer value | 0.33 ug/mL |
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Date of test | 2024-1-20 |
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Body temperature | 36.4 ℃ |
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Systolic pressure (SP) | 92 mmHg |
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Diastolic pressure (DP) | 58 mmHg |
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Heart Rate, HR | 84 次/分 |
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Pulse | 84 次/秒 |
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WBC | 13.3 ×109 /L |
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NEUT% | 89.57 % |
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LY% | 6.16 % |
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MONO％ | 3.95 ％ |
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RBC | 3.95 ×10^12 /L |
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HGB | 116 g/L |
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PLT | 190 ×10^9 /L |
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Date | 2024-1-20 yyyy-mm-dd |
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Pain Visual Analogue Score | Occasionally very slight pain
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sample collection | Collected
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Volume | 1 ml |
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Time of collection | 2024-1-20 yyyy-mm-dd-hh-min. |
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Label Number of the sample | 2558621 |
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Date received at DCC | -- yyyymmdd |
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Report type | |
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Name of this event | -- |
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SAE start date | -- yyyymmdd |
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SAE stop date | -- yyyymmdd |
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Was this an unanticipated adverse event | |
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Attribution to Study Drug | |
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Outcome Type(check all that apply) | |
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Recovery Description: (check only one) | |
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Please provide a brief narrative of the SAE occurrence below | -- |
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Name of the recorder | -- |
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Data | -- yyyymmdd |
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Site Investigator’s signature | -- |
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Data | -- yyyymmdd |