ID information
Hospital ID:
Physician ID:
Date:
Case ID:
General Information (case number: No- )
Birthday:
BW:
kg
BH:
cm
Sex:
Patient history:
(
Rutherford classification:
Class
Medications:
Laboratory data (within 6 month)
WBC account:
Platelet account:
Neutro(%):
Lympho (%)
Albumin: mg/dl
Hct: mg/dl
AC sugar: mg/dl
HbA1C: %
BUN: mg/dl
Cre: mg/dl
Uric acid: mg/dl
Platelet account:
Neutro(%):
Lympho (%)
Albumin: mg/dl
Hct: mg/dl
AC sugar: mg/dl
HbA1C: %
BUN: mg/dl
Cre: mg/dl
Uric acid: mg/dl
GOT/GPT:
/ U/L
Total Chol: mg/dl
TG: mg/dl
LDL: mg/dl
HDL: mg/dl
Total Chol: mg/dl
TG: mg/dl
LDL: mg/dl
HDL: mg/dl
CRP:
註: LDL, HDL 請以檢測的實際資料帶入 (3個月內為有效數值)
Test or image evaluation before index angiography
Rt
Rt
(if ABI level ≥1.3)
Concurrent image modality during index angiography