Digicon

@if (isset(session()->get('doctor')['vCentralCode']))

Back

@else

@endif

Patient {{ $iPatientNo }}

(Kindly fill in the relevant information or tick, as appropriate.)

Doctor’s Details

@if(isset(session()->get('doctor')['vCentralCode']))

Name of Doctor *

@else

Name of Doctor *

@endif

Registration No*

Qualification *

Specialty*

Hospital/Clinic Address *

City*

State *

Patient’s Details

Initials *

OPD/IPD Registration No*

Gender *

Male Female

Age (in Years) *

City/Town *

State *

Diagnosis of dermatophytosis *

General Examination Findings

Pulse (per minute) *

Blood Pressure (Systolic mmHg) *

Diastolic (mmHg) *

Weight (in cm) *

Height (mmHg) *

Body Mass Index (BMI) kg/m² *

Dermatophytosis: Duration *

Less than 2 weeks 2-4 weeks 6-12 weeks >12 weeks

Family History *

Not Applicable (N/A) Past or current H/O dermatophytosis in family members Any Other

H/O co-morbidities

Diabetes*

Yes No

Hypertensions*

Yes No

Liver impairment*

Yes No

Obesity*

Yes No

H/O Any Other Immunocompromised conditions

HIV*

Yes No

Cancer*

Yes No

Undernutrition*

Yes No

Any Other

H/O treatment taken for the current condition

Topical antifungal*

Yes No Any Other

Systemic antifungal*

Yes No Any Other

Topical corticosteroid + antifungal*

Yes No Any Other

Anti-fungal topical therapy given*

Drug Class and Drug (generic name only)	Frequency of dosing	Duration
Drug Class and Drug (generic name only)		OD BID TID
	OD BID TID
	OD BID TID

Anti-fungal systemic therapy Details *

Drug Class and Drug (generic name only)	Frequency of dosing	Duration
Drug Class and Drug (generic name only)		OD BID TID
	OD BID TID
	OD BID TID

Anti-histamine Therapy Details (if prescribed)

Drug Class and Drug (generic name only)	Dose/Strength (in mg unless specified)	Frequency of dosing	Duration
Drug Class and Drug (generic name only)			OD BID TID
		OD BID TID

Moisturizers (if prescribed)

Drug Class and Drug (generic name only)	Frequency of dosing	Duration
Drug Class and Drug (generic name only)		OD BID TID
	OD BID TID
	OD BID TID

Other medications prescribed

Drug Class and Drug (generic name only)	Frequency of dosing	Duration
Drug Class and Drug (generic name only)		OD BID TID
	OD BID TID
	OD BID TID

General measures suggested (Ex. Loose fitting cotton clothes, to not share towels etc) *

Recommendation given (Check applicable)	Adherence observed in the patient (Check applicable)
Recommendation given (Check applicable)		Compliant* Non-compliant
	Compliant* Non-compliant
	Compliant* Non-compliant
*Compliant: 75% Adherence to the lifestyle modification advice