Haiti Spinal Cord Injury Database - Patient

 Haiti Spinal Cord Injury Database -­ Patient information required Full name Date of birth/age Gender Address Telephone number(s) Injury date Injury history SCI level of injury Injury mechanism (fall, earthquake, violence, vehicle, other) ASIA score Last hospital Other information/comments NGO assistance (name/type of assistance) Date of death Reason for death Please email information – marked confidential – to: Fiona Stephenson RN, Haiti SCI Database Coordinator. [email protected] Telephone: +50938922332 for further information Haïti Database Spinal Cord Injury Information pertinente des patients médullolésés Nom complet…………………………………………………………………………………………………… Date de naissance…………………………………………………………………………………………….. Âge………………………………………………………………………………………………………………… Sexe…………………………………………………………………………………………………………………. Adresse……………………………………………………………………………………………………………. Numéro de téléphone (s)………………………………………………………………………………….. Date des blessures………………………………………………………………………………………....... historique des blessures…………………………………………………………………………………… Niveau des blessures de SCI……………………………………………………………………………… Mécanisme de blessure (chute, tremblement de terre, la violence, des véhicules… autres)……………………………………………………………………………………………………………... Score ASIA……………………………………………………………………………………………………….. Dernier hôpital ……………………………………………………………………………………………...... Autres informations / commentaires………………………………………………………………… ONG d'aide (nom / type d'assistance)………………………………………………………………... Date du décès…………………………………………………………………………………………………… Raison de la mort……………………………………………………………………………………………… S'il vous plaît, email les informations - marquées confidentielles -à
Fiona Stephenson RN, Haiti SCI Database Coordinator. [email protected] Téléphone: +50938922332 pour plus de renseignements