realted

1. CASE HISTORY
General information:
Name:
Age:
Gender:
Occupation:
Address:
Contact number:
Chief complaint:
History of presenting illness:
Past medical history:
Drug history:
General physical examination:
Vitals:
 Blood pressure:
 Pulse rate:
 Respiratory rate:
 Temperature:

2. Extra oral examination:
 Mouth opening:
 Tenderness:
 Swelling :
Intra oral examination:
Soft tissue examination:
Mucosa:
Palate:
Gingiva:
Hard tissue examination:
Teeth present:
Missing Teeth :
Carious teeth:
Occlusion:
Overjet:
Over bite:
Supraerupted teeth:
Edentulous area dimensions:
Mesiodistal width:
Buccopalatal width:
Provisional diagnosis:
Blood investigations:
 Clotting time
 Bleeding time
 RBS.

3.  HbA1C
 HIV
 HbSAg
 Complete blood count:
Radiographic investigations:
OPG:
CBCT:
Final diagnosis:
Model analysis:
Treatment plan:
Treatment executed:

4. Follow up:
INFORMED CONSENT FORM (ICF)
Title: ROLE OF PLATELET RICH FIBRIN MEMBRANE (PRF) AS A PERI-IMPLANT
GRAFT MATERIAL IN LATERAL SINUS LIFT PROCEDURES – A PROSPECTIVE
STUDY.
Principal Investigator: DR. RAJAGIRI BALA SUNDARA RAJU.
Department of Oral and Maxillofacial Surgery, Anil Neerukonda Institute of Dental Sciences,
Vizianagaram.
Name: Age: Gender:
Occupation:
Address: phone no:
Having been informed about the aim, objectives and the procedure of the said research project, I am
agreeing to reveal information required for the research and allowing the investigator and his team
to utilize my blood for the same purpose without disclosing my identity. I was explained about
Confidential
Op No. __________

5. problems regarding local anesthesia and also understand that the participation is completely
voluntary and I can withdraw myself from the study anytime without assigning any reason and this
will not affect my ongoing and future treatment.
నాకుపరిశోధనయొక్క లక్ష్య ంమరియువిధివిధానములన్ని టిగురించిపరిశోధనబ ందం
చేవిశదీక్రిండంఅయంది. వారికికావలసినసమాచారముసవ చ్చ ందంగాతెలియజేయుచు
నాి ను.
నావయ కి ి
గతవివరములుబయటపెటటకుండానేనుఇచిచ నసమాచారము,నాశరీరమునుండి
తీసినరక్ ి
ం, పరిశోధనన్నమితింఉపయోగంచుటకునేనుమనస్పూ రిిగాఅంగీక్రిస్తినాి ను.
నాకుమత్తుఇవ్వ డంవ్లనకలిగేఅనర్దా లువివ్రంచడంజరగంది.ఇందులోనాపైఎవరివత్తి
డిలేదు.అంతేగాకుండానేనుఏకారణముచేతనైననుఎప్పూ డైననుఈపరిశోధననుండివైదొ
లగేఅవకాశంకూడానాకుక్లదు. నేనుపూరిితెలివితోసవ చ్చ ందంగాఈఅంగీకారముతెలుప్ప
చునాి ను.
Signature of Witness Signature of the Participant
సాక్షిసంతక్ం పాల్గ
ొని వారిసంతక్ం

6. INVESTIGATIONS NORMAL VALUES
PATIENT
VALUES
COMPLETE BLOOD PICTURE
RBC 3.5-4.5 millions/cumm
WBC 6350 cells/cumm
PLATELET COUNT 1.5-4.0 lakhs/cumm
MEAN CELL VOLUME 82.2 fl
MEAN CELL HEMOGLOBIN
CONCENTRATION 27.9 pg
MEAN CELL HEMOGLOBIN
CONCENTRATION 33.90%
DIFFERENTIAL COUNT
POLYMORPHS 45 – 75 %
LYMPHOCYTES 20 – 40%
EOSINOPHILS 1 – 6%
MONOCYTES 2 – 10 %
BASOPHILS 0 – 1%
HEMOGLOBIN 12- 16 gm%
BLEEDING TIME 2 – 7 minutes
CLOTTING TIME 3 – 10 minutes
PROTHROMBIN TIME 11 - 14 sec

7. ACTIVATED PROTHROMBIN
TIME 30 – 40 sec
FASTING BLOOD SUGAR 80- 100mg/dl
RANDOM BLOOD SUGAR < 200md/dl
HBA1C 5-6 %
SERUM CALCIUM 8.4-10.4 mg/dl
SERUM CREATIN 0.8 – 1.2 mg/dl
SERUM PHOSPHORUS 2.5-4.5 mg/dl
VITAMIN D3 20-40ng/ml
URIC ACID 4-8.5mg/dl
TRIPLE SCREENING
HIV I & II Negative
HBsAg Negative