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EK-1
HASTA BĐLGĐ FORMU
:
Hastanın kimlik bilgileri : Hasta :
Kontrol
:
Adı- soyadı : Cinsiyeti: K E
Çalışmaya alınma tarihi:
56
Protokol no:
Doğum tarihi:
Telefon no:
Hastanın risk profili:
Hipertansiyon: var yok
Dislipidemi: var yok
KAH: var yok
Sigara: içmemiş bırakmış içiyor
Alkol: kullanmıyor <1kez/ay 1-2kez/ay
1-2kez/hafta 3-4kez/hafta hergün
Egzersiz: yapmıyor <1kez/hafta
1-3kez/hafta >4kez/hafta
Hastanın kullandığı ilaçlar:
Antihipertansif ilaç: kullanıyor kullanmıyor
Antihiperlipidemik ilaç: kullanıyor kullanmıyor
Tiroid ilacı: kullanıyor kullanmıyor
Diğer ilaçlar: .........
Antropometrik ölçümler:
Kan basıncı : Sağ : / mmHg
Sol : / mmHg
NDS : /dakika
57
Boy : c / cm Kilo: /kg
Bel çevresi: /cm Kalça çevresi: /cm
Biyokimyasal analiz:( Hastanın dosyasından kaydedilecektir)
Açlık plazma glukozu: ........mg/dl Kalsiyum: .......mg/dl
Kreatinin: .........mg/dl Fosfor: ........mg/dl
Trigliserid: ........mg/dl Albümin: .......gr/dl
Kolesterol: ........mg/dl TSH: ........uIU/ml
HDL: ..........mg/dl Anti TPO: .........IU/ml
LDL: ..........mg/dl Anti Tg: ...... IU/ml
AST( SGOT): .........U/L ALT(SGPT): ..........U/L
Çalışmada bakılacak olan özel tetkikler:
PTH: .........pg/ml
25-OH D vitamini: .........ng/ml
EK-2
BĐLGĐLENDĐRĐLMĐŞ HASTA OLUR FORMU
Sayın katılımcımız;
Sağlık Bakanlığı Göztepe Eğitim ve Araştırma Hastanesi Endokrinoloji ve Đç Hastalıkları
polikliniklerinde yürütülmesi planlanan bu çalışmada yer almanız isteğinize bağlıdır.
58
Çalışmaya katılmayı reddetme ve çalışmanın herhangi bir aşamasında ayrılma hakkına
sahipsiniz. Bu durum cezai bir yükümlülüğe veya daha sonraki tedaviniz için herhangi bir
olumsuzluğa ve engele yol açmayacaktır.
Daha önce yapılan çalışmalarda, patogenezinde inflamasyonun rol aldığı kanser, multıpl
skleroz, romatoid artrit, sistemik lupus eritematozus, hipertansiyon, koroner kalp hastalığı,
metabolik sendrom ve diabetes mellitus gibi hastalıklarda Dvitamini yetersizliğinin sık olduğu
görülmüştür. Bu çalışmada tiroidin en sık rastlanılan otoimmun hastalığı olan Hashimoto
tiroiditinde PTH ve D vitamini düzeyi araştırılacaktır.
Çalışmamıza katılımınız halinde 1 kez kliniğe çağrılacaksınız. Çalışmaya katılmayı kabul
eden hastalarımızın fizik muayenesinde sağ ve sol koldan kan basıncı, boy, kilo, bel çevresi ve
dakika nabız sayısı ölçülecektir. Ayrıca biyokimya parametreleri, PTH ve 25- Hidroksi D
vitamini düzeyleri için kan örnekleri alınacaktır. Çalışmamızda hayatı tehdit edecek herhangi
bir tehlike bulunmamaktadır. Bu çalışmadan elde edilen sonuçlar, kimliğiniz açıklanmadan
sadece bilimsel amaçlarla
yayınlanacaktır. Elde edilen test sonuçları hakkında
bilgilendirilceksiniz. Bu olur formunun bir örneği size verildikten sonra çalışmaya
başlanacaktır. Çalışmamız, hastane etik kurulundan izin alınarak gerçekleştirilecektir. Çalışma
Prof.Dr. Aytekin Oğuz gözetiminde Asist. Dr. Safiye Arık tarafından yürütülecektir. Herhangi
bir sebeple 05547315525 numaralı telefonlara ulaşabilirsiniz. Katılımınız için teşkkür ederiz.
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