Form Genoe-F04 - Client Service Receipt Inventory Form
ADVERTISEMENT
1GENOE-F04
Client Service Receipt Inventory Form
Short Form (BADS-SF)
Trial ID:
Date Completed:
Patient Name: _________________
CSRI PART B
1 Yes
In the last 3months, have you had any X-rays,
7
Blood Tests, ECG, ultrasound, scans or any other tests?
0 No
Cost of test
If yes, please
NOTE_1: For government tests,
If yes,
7.1
Who from?
(include
specify
note the actual tests from case
description of test
travel)
the tests
notes; for private tests you may
take total costs of all tests in
1= Govt.Lab
case there are no detailed
Rs.
2= Pvt.Lab
receipts or prescription.
3= Other (specify)
1= Govt.Lab
Rs.
2= Pvt.Lab
3= Other (specify)
NOTE_2: if tests are repeated,
list each separately.
1= Govt.Lab
Rs.
2= Pvt.Lab
3= Other (specify)
WHERE AVAILABLE, AND
1= Govt.Lab
WITH THE PATIENT'S
Rs.
2= Pvt.Lab
PERMISSION, TAKE
3= Other (specify)
A PHOTO OF THE
1= Govt.Lab
PRESCRIPTION
2= Pvt.Lab
Rs.
DESCRIBING
3= Other (specify)
THE TESTS
1= Govt.Lab
Rs.
TOTAL
2= Pvt.Lab
3= Other (specify)
1 Yes
In the last 3 months, have you taken tablets,
8
medicines or injections?
0 No
If yes,
Type:
Quan
Dosage
Cost of Drugs
8.1
Consump
1 Paid
1 Tablet
Name/
bought/given
(i.e.,
(if available:
past 3 months
2 Syrup
0 Free
Description
e.g. 1 Bo
strength of
total cost of
3 Injections
Per day
No. of
of drug
1 strip of 10 tablets
medica
last 3 months)
4 Ointment
Days
e.g.
5 Spray
(last 3 months)
in mg/ml, etc.)
tablets/
6 Drops
7 Powder
teaspoons
8 Others
(specify)
TOTAL
INTERVIEWER NOTE: The aim of this table is to list all medicines and the duration taken so that the amount of rupees can be calculated;
however, if the subject is unaware of these details, the total amount of money spent in the past 3 months can also be entered in the
Total Box. A subject may only know how much is spent each week; in this case, multiply the weekly cost by 12 to get the 3 - month total)
WHERE AVAILABLE, AND WITH THE PATIENT'S PERMISSION, TAKE A PHOTO OF THE PRESCRIPTION DESCRIBING THE MEDICINES.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business