Form Genoe-F03 - Client Service Receipt Inventory Form Page 3
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4GENOE-F03
Client Service Receipt In ventory Form
Short Form (BADS-SF)
1 Yes
6
In the last 9 months, has the pa ent, a family member or friend had
to stop or reduce usual work / ac vi es due to your ill-health?
0 No
6.1
Family / friend 2
Pa ent
Family / friend 1
If yes,
6.2
No. of days in the last 9 months
Type of work/educa on forgone (1-4; see key)
6.3
Key: Type of work forgone:
1 = unpaid housework (e.g. housewife)
2 = manual work (e.g. agricultural or
factory worker)
3 = office / non-manual work (e.g. skilled
worker, business, professional)
4 = student
Rs.
6.4
Rs.
If applicable, income lost per day
Rs.
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
descrip on 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 prescrip on.
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
Rs.
2=Pvt.Lab
DESCRIBING
3= Other (specify)
THE TESTS
1=Govt.Lab
Rs.
TOTAL
2=Pvt.Lab
3= Other (specify)
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Parent category: Business