Digicon

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

Name of Doctor*

@else

Name of Doctor *

@endif

Registration No. *

Qualification *

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

Speciality *

@else

Speciality *

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

Hospital/Clinic Address *

@else

Hospital/Clinic Address *

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

City *

@else

City *

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

State *

@else

State *

@endif

Patient’s Details

Initials *

OPD/IPD Registration No *

Gender *

Male Female

Age (in Years) *

City/Town *

State *

Smoker *

Current Former Never

General Examination Findings

Pulse (Per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

Tick any one of the below *

Overweight Obese

Heart Failure *

Yes No

Years since diagnosis

Less than 1 yr 1 to <5 yrs 5 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

Number of re-hospitalizations with current anti-heart failure medication therapy up to 1 year*

Number of visits to emergency department of hospital with current anti-heart failure medications therapy up to 1 year *

Type 2 Diabetes Mellitus *

Yes No

Hypertension *

Yes No

Diagnosed since

Less than 1 yr 1 to <5 yrs 5 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

Chronic Kidney Disease (CKD) *

Yes No

If Yes, Years since diagnosis

Less than 1 yr 1 to <5 yrs 5 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

History of Coronary Artery Disease (CAD): *

Yes No

History of Valvular Heart Disease: *

Yes No

History of Congenital Heart Disease: *

Yes No

History of Myocardial Infarction: *

Yes No

History of Dilated Cardiomyopathy: *

Yes No

History of Hypertrophic Cardiomyopathy: *

Yes No

History of Myocarditis: *

Yes No

History of Anemia: *

Yes No

If Yes, haemoglobin level (mg/dl)

History of Arrhythmia: *

Yes No

If Yes, type of Arrhythmia:

Peripheral vascular disease: *

Yes No

If Yes, Years since diagnosis:

Less than 1 yr 1 to <5 yrs 5 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

Heart Failure Specific drug regimen *

Drug Class and Drug (generic name only)	Dose/Strength (in mg unless specified)	Frequency of dosing	Order of Sequence
Beta Blocker
Bisaprolol	1.25 2.5 5 10	OD BID TID	First Second Third Fourth
Metaprolol	50 100	OD BID TID
Carvedilol	3.125 6.25 12.5 25	OD BID TID
MRA
Eplerenone	25 50	OD BID TID	First Second Third Fourth
Finerenone	10 20	OD BID TID
Spironolactone	25 50 100	OD BID TID
SGLT2i
Dapagliflozin	5 10	OD BID TID	First Second Third Fourth
Empagliflozin	10 25	OD BID TID
Canagliflozin	100 300	OD BID TID
Remogliflozin	100	OD BID TID
Diuretics
Chlorthalidone	6.25 12.5	OD BID TID	First Second Third Fourth
HCTZ	12.5	OD BID TID
Furosemide	20 40 80	OD BID TID
Torsemide	5 10 20 60 100	OD BID TID

Anti-Hypertensive Therapy Details

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

Lipid Lowering Therapy Details

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

Anti-platelet / Aspirin Therapy Details

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

Investigations

Glycemic Profile:

HbA1c(%)*

Fasting Plasma Glucose(mg/dl)*

Post-prandial Plasma Glucose(mg/dl) *

Lipid Profile:

Total Cholesterol(mg/dl)*

LDL-C(mg/dl)*

HDL-C(mg/dl) *

VLDL-C(mg/dl) *

Triglycerides(TG)(mg/dl) *

Non-HDL(mg/dl) *

{{ $ActivityTypeName }}

Patient {{ $iPatientNo }}

Doctor’s Details

Patient’s Details

General Examination Findings

Heart Failure Specific drug regimen *

Anti-Hypertensive Therapy Details

Lipid Lowering Therapy Details

Anti-platelet / Aspirin Therapy Details

Investigations

Glycemic Profile:

Lipid Profile:

Heart Failure specific bio markers : if done

2D ECHO