CONSENT FORM

I have been informed that I am being involved as a subject in a study

which will analyse "STUDY OF RIGHT VENTRICULAR FUNCTION,
LEFT VENTRICULAR SYSTOLIC AND DIASTOLIC FUNCTION IN
NON DIALYSIS DEPENDENT CKD PATIENTS". I have also been
informed that the result of this study may help doctors to make timely
decision for cardiac evaluation and its implementation in CKD patients which
will help in improving quality of many lives.

I know that as a part of this study, I will have to spend a few minutes
answering questions related to my health and my blood investigations, urine
analysis and some other investigations will be done as necessary.

I have been informed to my satisfaction that information given by me

will not be disclosed to anyone without my permission. I also know that for
any inquiry I can always contact Dr. Sreenidhi H C, SR, Department of
Nephrology, IMS, BHU, Varanasi or Dr. Shivendra Singh, Professor and
Head of Department, Department of Nephrology, IMS, BHU, Varanasi.

After knowing all these facts in detail, I agree to be a part of this

research work. Further it is not compulsory for me to continue to be part of
this study and I can anytime opt out during the course of the research work on
my desire.

Name of Patient :

Signature :

Date :

Name of the Candidate :

 lgefr i=
izLrkouk &
vki ls vkxzg fd;k tkrk gS fd fpfdRlk foKku laLFkku] lj lqUnj
yky vLirky] ch0,p0;w0] okjk.klh ds o`Dd jksx ds varjax foHkkx esa
gksus okys ^^LVMh vkWQ jkbV osUVªhdqyj QaD'ku] ys¶V
osUVªhdqyj lkbLVksfyd ,.M MkbLVksfyd QaD'ku bu uku
ykbfyfll fMisUMsaV lh0ds0Mh0 islsUV** bl v/;;u esa Hkkxhnkjh
vkidh Lok;Rrrk ij fuHkZj gSA vki fdlh Hkh le; bl v/;;u esa Hkkx
ysus ls euk dj ldrs gS vkSj viuh Hkkxhnkjh ls eqDr gks ldrs gSA
blls vkidks feyus okys bykt ij dksbZ izHkko ugha iM+sxkA d`i;k bl
lgefr i= dks xgurk ls i<+s vkSj gLrk{kj djus ls igys vius fpfdRld ls
viuh 'kadkvksa dk lek/kku dj ysaA
fooj.k &
vxj vki bl v/;;u esa viuh Hkkxhnkjh ls lger gS rks vkids jDr
vkSj is'kkc dk lSEiy fy;s tk;saxs ,oa fdMuh ck;ksIlh fd;s tk ldrs
gSaA blds vfrfjDr ge vkils] vkids vLirky fjdkMZ ls vko';d vk¡dM+s
,d= djus dh vuqefr ysaxsA vxj vki bl v/;;u esa Hkkx ugha ysuk
pkgrs gSa rks blls vkids bykt ij dksbZ izHkko ugha iM+sxkA
ykHk &
blls v/;;u ds nkSjku vkidh Hkkxhnkjh ls gesa vkids bykt dks
csgrj djus ls lgk;rk feysxh ,oa bl v/;;u ds ifj.kkeksa ls Hkfo"; esa
vkus okys jksfx;ksa dks ykHk feysxkA
xksiuh;rk &
vkidh Hkkxhnkjh ls lEcfU/kr rF;ksa dk iw.kZr% xksiuh; j[kk
tk;sxk vkSj dsoy vuqla/kku ds fy;s iz;ksx fd;k tk;sxkA vuqla/kkfud
lnL;ksa ds vykok dksbZ Hkh O;fDr vkidks mRrj ,oa ifj.kke ugha
tku ik;sxkA vkidk uke fdlh Hkh fjiksVZ esa fdlh Hkh rjg ls ugha
vk;sxkA
lgefr &
 eSaus iwjh rjg bl v/;;u ds fooj.k dks i<+ fy;k gS vkSj viuh
'kadkvksa dk lek/kku dj fy;k gSA eSa bl v/;;u esa Hkkxhnkjh ds
fy;s lger gw¡A

-------------------------------------- ----------------------------------
---------- ---------------------------------------
jkssxh ds gLrk{kj lk{kh ds gLrk{kj
fnukad
 CONSENT FORM
I have been informed that I am being involved as a subject in
"OBSERVATION STUDY OF THE EPIDEMIOLOGICAL".

I know that as a part of this study, I will have to spend a few minutes
answering questions related to my health and my blood investigations, urine
analysis and some other investigations will be done as necessary.

I have been informed to my satisfaction that information given by me

will not be disclosed to anyone without my permission. I also know that for
any inquiry I can always contact Dr. Manjitpal Singh, SR, Department of
Nephrology, IMS, BHU, Varanasi or Dr. Shivendra Singh, Professor and
Head of Department, Department of Nephrology, IMS, BHU, Varanasi.

After knowing all these facts in detail, I agree to be a part of this

research work. Further it is not compulsory for me to continue to be part of
this study and I can anytime opt out during the course of the research work on
my desire.

Name of Patient :

Signature :

Date :

Name of the Candidate :

 lgefr i=
izLrkouk &
vki ls vkxzg fd;k tkrk gS fd fpfdRlk foKku laLFkku] lj lqUnj
yky vLirky] ch0,p0;w0] okjk.klh ds o`Dd jksx ds varjax foHkkx esa
gksus okys ^^,u oksCtjos'kuy LVMh vkWQ n
,ihMsek;ksyksftdy] fDyfudy ,.M yscksjsVjh izksQkby vkQ
,y0th0 , uSQjksisFkh** bl v/;;u esa Hkkxhnkjh vkidh Lok;Rrrk ij
fuHkZj gSA vki fdlh Hkh le; bl v/;;u esa Hkkx ysus ls euk dj ldrs
gS vkSj viuh Hkkxhnkjh ls eqDr gks ldrs gSA blls vkidks feyus
okys bykt ij dksbZ izHkko ugha iM+sxkA d`i;k bl lgefr i= dks
xgurk ls i<+s vkSj gLrk{kj djus ls igys vius fpfdRld ls viuh
'kadkvksa dk lek/kku dj ysaA
fooj.k &
vxj vki bl v/;;u esa viuh Hkkxhnkjh ls lger gS rks vkids jDr
vkSj is'kkc dk lSEiy fy;s tk;saxs ,oa fdMuh ck;ksIlh fd;s tk ldrs
gSaA blds vfrfjDr ge vkils] vkids vLirky fjdkMZ ls vko';d vk¡dM+s
,d= djus dh vuqefr ysaxsA vxj vki bl v/;;u esa Hkkx ugha ysuk
pkgrs gSa rks blls vkids bykt ij dksbZ izHkko ugha iM+sxkA
ykHk &
blls v/;;u ds nkSjku vkidh Hkkxhnkjh ls gesa vkids bykt dks
csgrj djus ls lgk;rk feysxh ,oa bl v/;;u ds ifj.kkeksa ls Hkfo"; esa
vkus okys jksfx;ksa dks ykHk feysxkA
xksiuh;rk &
vkidh Hkkxhnkjh ls lEcfU/kr rF;ksa dk iw.kZr% xksiuh; j[kk
tk;sxk vkSj dsoy vuqla/kku ds fy;s iz;ksx fd;k tk;sxkA vuqla/kkfud
lnL;ksa ds vykok dksbZ Hkh O;fDr vkidks mRrj ,oa ifj.kke ugha
tku ik;sxkA vkidk uke fdlh Hkh fjiksVZ esa fdlh Hkh rjg ls ugha
vk;sxkA
lgefr &
 eSaus iwjh rjg bl v/;;u ds fooj.k dks i<+ fy;k gS vkSj viuh
'kadkvksa dk lek/kku dj fy;k gSA eSa bl v/;;u esa Hkkxhnkjh ds
fy;s lger gw¡A

-------------------------------------- ----------------------------------
---------- ---------------------------------------
jkssxh ds gLrk{kj lk{kh ds gLrk{kj
fnukad