Acute Form 2004 - Riks-Stroke printable pdf download

Acute Form 2004 - Riks-Stroke

Version 7.0. To be used for all stroke registrations from 1 April 2004 onwards

- A

IKS

STROKE

CUTE

HASE

Personal ID number

I___I___I___I___I___I___II___I___I___I___I

Sex

1= male 2= female

I___I

Name

Address

Telephone

Optional information (for instance, name and telephone number of family member)……………………………

…………………..……….…………..……………………………………………………………………………….………

Reporting hospital

I___I___I___I

Department/ward

I___I___I___I

Date of registration

I___I___II___I___II___I___I

Year/Month/Day (yy/mm/dd)

Completed by (name of person who completed this form) ........................….........……………..……..…………

-------------------------------------------------- PRIOR TO STROKE ---------------------------------------------

Living

I___I

1= in own home without community support

2= in own home with community support

3= living in a community facility (for instance service flat with full board, short stay pension,

old peoples’ home, nursing home or equivalent)

5= other (fill in)

Other ...................................……….......…….……......…………….

Living alone

I___I

1= the patient lives on his/her own

2= the patient lives with a spouse/partner or another person, for instance family member

Mobility

I___I

1= the patient was able (prior to this illness) to move around without supervision

indoors as well as outdoors (use of support or walking stick allowed)

2= the patient was able to move around by his/her own indoors but not outdoors

3= the patient was assisted by another person when moving around or he/she was bedridden

Toilet visits

I___I

1= the patient managed toilet visits on his/her own

2= the patient was unable to go to the toilet unaided, or used bedpan or incontinence pads

or needed assistance in wiping him/herself or in dressing

Dressing

I___I

1= the patient was able to dress without assistance, including outdoor clothes, socks/stockings

and shoes, or needed assistance only in tying shoelaces

2= the patient needed assistance to fetch clothes, or needed assistance in dressing/undressing

or remained undressed

Acute Form 2004 - Riks-Stroke

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