ACS – FQ
Phone
*
Call Done by
*
Fatema Khanam Baby
Shahi Israt Jahan
Maisha Farzana
Present status of the patient
Alive
Dead
Date of Call
Follow-up Call Result
Complete, received patient him/herself
Complete, received someone other than patient
Patient is not responding
Phone number does not work
Refused to talk
Other reason
Others (Please specify)
Any hospitalization?
Yes
No
Which hospital
UHC
District Hospital
Govt. Medical College Hospital
Specialized govt.hospital
General Private Hospital
Specialized Private Hospital
NA
Cause of hospitalization
Chest pain
True
False
Heart attack
True
False
Arrhythmia
True
False
Cardiomyopathy
True
False
Stroke
True
False
Deep vein thrombosis
True
False
Chronic kidney disease
True
False
Routine intervention (CAG/PCI/CABG)
True
False
Other
True
False
Others (Please specify)
Date of admission
Intervention ?
CAG
PCI
CABG
Regular intake of medication?
Yes
No
Cause of not taking regular medicine:
Feeling well
Financial crisis
Family noncooperation
Medicine is not available locally
Other reason
Others (Please specify)
Name of the drugs (ওষুধ তো দামী, কোনটা কোনটা খেতে পারছেন?)
Aspirin
Yes
No
Clopidogrel/Prasugrel/Ticagrelor
Yes
No
Atorvastatin / Rosuvastatin
Yes
No
ACEI/ ARB
Yes
No
ARNI
Yes
No
B blocker
Yes
No
CCB
Yes
No
Nitrates
Yes
No
Diuretics
Yes
No
Enoxaparin
Yes
No
Heparin
Yes
No
Trimetazidine
Yes
No
Nicorandil
Yes
No
Ranolazine
Yes
No
Inotropes
Yes
No
Date of death
Place of death
Home
Hospital
Cause of death, with verification (if possible, by contacting with respective hospitals)
Cardiac cause (Heart failure/heart attack/pulmonary embolism/sudden cardiac death)
Stroke
Chronic kidney disease
Infectious disease (pneumonia/diarrhea/septicemia/dengue/other)
Injury/ trauma
Age-related natural death
Others (Please specify)
Submit