Osteomyelitis Recurrence Data Form
Please complete this form to document key data on osteomyelitis recurrence cases. All fields are required for accurate record keeping.
Patient Initials
*
Age (years)
*
Sex
*
Male
Female
Other
Date of Recurrence Diagnosis
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Site of Recurrence
*
Please Select
Long bone
Spine
Foot
Pelvis
Other
Presenting Symptoms
*
Pain
Swelling
Redness
Discharge
Fever
Other
How was recurrence confirmed?
*
Clinical exam
Imaging (X-ray/MRI/CT)
Microbiology
Laboratory markers
Other
Risk Factors Present
*
Diabetes
Peripheral vascular disease
Immunosuppression
Previous surgery
Other
Previous Treatment for Osteomyelitis
*
Please Select
Antibiotics only
Surgery and antibiotics
Other
Current Management of Recurrence
*
Please Select
Antibiotics only
Surgery and antibiotics
Observation
Other
Outcome (if known)
*
Please Select
Resolved
Ongoing infection
Complications
Unknown
Submit
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