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Untitled - Memorial University's Digital Archives Initiative - Memorial ...

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STUDY FORM B: Page 5<br />

Bima nual Pa lpation<br />

uterus .... ..•.Size < 12 wks:<br />

Tende rness Pr e s en t :<br />

Adnexal tende r ness Present:<br />

c e r v.tx as dilated:<br />

Lower Extremities !&..f..t.<br />

Evidence of t hrombophlebitis<br />

>12 weeks:<br />

ab s en t :<br />

absent :<br />

as closed:<br />

o t he r abnorma l finding s (p lease s tate' _<br />

SECTION C' LA BORATORY<br />

Blood spe cimen 2 (Day 7-10) Samp le number _<br />

time c ol lected<br />

247<br />

RESULTS : PRE- DELI VERYSAMPLE (g/dl )<br />

SECTION O' OUTCOMES OF FO JlOW np<br />

Diagnosis: 1. _<br />

2 . _<br />

3 . _<br />

POST-DELIVE RY SAMPLE (g/dl)<br />

Refer red<br />

Tr eated<br />

Well

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