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PHỤ LỤC 1

BỆNH ÁN NGHIÊN CỨU

Mã số:

1. Họ tên bệnh nhân: 2. Năm sinh: 3. Nam, Nữ

4. Địa chỉ:

5. Số điện thọai: 6. Nghề nghiệp:

7. Bệnh sử:

8. Đã điều trị nội khoa:

9. Đã phẫu thuật mũi:

10. Tiền căn bệnh khác:

11. Đến khám lần đầu ngày:

12. Thời gian theo dõi: từ ngày đến ngày

13. Triệu chứng: Lâm sàng:

1. Hình ảnh:

2. Nghiệm pháp Cottle:

3. Nghiệm pháp Cottle cải tiến:

4. Tự đánh giá mức độ nghẹt mũi: Cận lâm sàng

5. CT scan:

6. Góc van mũi trong:

7. CSAmin:

8. Nội soi mũi xoang:

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