CASE STUDY TEMPLATE
This form is intended to help you to start the construction of your case report.
YOUR DETAILS
Name of healthcare professional
First Name
Last Name
Email
example@example.com
PATIENT BACKGROUND
Patient (Initials only for anonymity please)
Gender
Male
Female
Other
Prefer not to say
Age group
Baby
Child
Adolescent
Adult
Elderly
Short description of build
Exercise
Daily
Weekly
Monthly
Infrequent
Not known
Family situation
Mental health
PATHOLOGY
Diagnosis
Acute or sudden onset
Acute
Sudden onset
Chronicity
Acute
Occasional
Main symptoms
Specificities / contributing factors (incl. genetics, lifestyle factors, diet)
Lab results
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TREATMENT PLAN
Treatment plan (evolution). Additional recommendations (lifestyle advice, dietary management
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