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PROFORMA

The document is a proforma for the ALIGN study, detailing preoperative and postoperative data for patients undergoing surgery. It includes sections for patient demographics, medical comorbidities, mobility scores, fracture mobility grades, complications, and follow-up assessments. The proforma is structured to collect comprehensive data on patient outcomes and recovery progress.

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Aravind Ravichandran
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31 views3 pages

PROFORMA

The document is a proforma for the ALIGN study, detailing preoperative and postoperative data for patients undergoing surgery. It includes sections for patient demographics, medical comorbidities, mobility scores, fracture mobility grades, complications, and follow-up assessments. The proforma is structured to collect comprehensive data on patient outcomes and recovery progress.

Uploaded by

Aravind Ravichandran
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

THE ALIGN STUDY PROFORMA

PREOP DATA
NAME: AGE: SEX:
DOS:
TIME OF SURGERY FROM TRAUMA:

MEDICAL COMORBIDITIES:________________________________________________
________________________________________________
TOTAL NO:
AO CLASSIFICATION CODE:
BOYD AND GRIFFIN CODE:
OSTEOPOROSIS GRADE(SINGH INDEX):
PARKER MOBILITY SCORE: [ /9]
WALKING ABILITY INDEPENDENT ALONE WITH WITH HELP FROM SCORE
ASSISTIVE ANOTHER
DEVICES PERSON
ABLE TO WALK INSIDE 3 2 1
THE HOUSE
ABLE TO WALK OUTSIDE 3 2 1
THE HOUSE

ABLE TO GO TO 3 2 1
SHOPPING

FRACTURE MOBILITY SCORE: GRADE__


GRADE I GRADE II GRADE III GRADE IV GRADE V
FREELY MOBILE WALKS WALKS SOME INDOOR NO FUNCTIONAL
WITHOUT AIDS OUTDOORS WITH OUTDOORS WITH MOBILITY NO MOBILITY
1 AID 2 AID OUTDOOR

POST OP DATA
POSTOP COMPLICATIONS
1.IMMEDIATE:______________________________________________________________________________
_______________________________________________________________________________

2. LONG TERM:____________________________________________________________________________
______________________________________________________________________________
IATROGENIC LATERAL WALL BROKEN: YES/NO
TIME OF FULL WEIGHT BEARING:
HIP THIGH PAIN AT 6 MONTHS: YES/NO
BAUMGAERTNER GRADE OF FRACTION: GOOD / ACCEPTABLE / POOR
NECK SHAFT ANGLE
IMMEDIATE POSTOP
AT 3 MONTHS FOLLOWUP
AT 6 MONTHS FOLLOWUP
CURRENT FOLLOWUP
CONTRALATERAL HIP

TIP APEX DISTANCE :


LENGTH OF FEMORAL NECK:
IMMEDIATE POSTOP
AT 3 MONTHS FOLLOWUP
AT 6 MONTHS FOLLOWUP
CURRENT FOLLOWUP
CONTRALATERAL HIP

PARKER MOBILITY SCORE: [ /9]


WALKING ABILITY INDEPENDENT ALONE WITH WITH HELP FROM SCORE
ASSISTIVE ANOTHER
DEVICES PERSON
ABLE TO WALK INSIDE 3 2 1
THE HOUSE
ABLE TO WALK OUTSIDE 3 2 1
THE HOUSE

ABLE TO GO TO 3 2 1
SHOPPING

FRACTURE MOBILITY SCORE: GRADE__


GRADE I GRADE II GRADE III GRADE IV GRADE V
FREELY MOBILE WALKS WALKS SOME INDOOR NO FUNCTIONAL
WITHOUT AIDS OUTDOORS WITH OUTDOORS WITH MOBILITY NO MOBILITY
1 AID 2 AID OUTDOOR

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