DigiCon

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

Name of Doctor *

@else

Name of Doctor *

@endif

Registration No. *

Qualification *

Speciality *

Hospital/Clinic Address *

City *

@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 *

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

State *

@else

State *

@endif

H/O Alcohol consumption: *

Yes No

Smoker *

Current Former Never

If Former, how long ago did patient quit smoking?

Unknown <6 months ago 6 months-1.5 years ago >1.5-2.5 years ago >2.5-3.5 years ago >3.5-5 years ago >5 years ago

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

Family History *

Not Applicable (N/A) Diabetes Hypertension Dyslipidemia Coronary Artery Disease Cerebrovascular Disease Chronic Kidney Disease Heart Failure Any Other

Type 2 Diabetes Mellitus Years since diagnosis*

03 to 5 yrs 05 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

CKD Years since diagnosis

<5 yrs 5-10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

CKD stages

Stage 1 Stage 2 Stage 3

Hypertension *

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

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

CKD management Agents Utilization

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

Anti-Hypertensive Agents Utilization *

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

Antidiabetic Agents Utilization *

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

Investigations

Renal Profile

Serum Creatinine (mg/dl)

Urine Albumin (mg/dl)

e-GFR (ml/min/1.73 m²)

Serum uric acid (mg/dl)

UACR (mg/g)

Renal Investigation Profile: (which ever data is available)

Glomerular Filtration Rate

eGFR

Sr. Creatinine

Creatine clearance

Blood Urea Nitrogen (BUN)

Cystatin C

Albuminuria

Proteinuria

Urine osmolality

Serum alkaline phosphatase (IU/l)

Serum calcium (mg%)

Serum inorganic phosphate (mg%)

Serum uric acid (mg%)

Serum sodium (mEq/l)

Serum potassium (mEq/l)

Serum chloride (mEq/l)

Blood pH

Bicarbonate (mmol/l)

Plasma anion gap

Urine (which ever data is available)

Clarity

Color

Urine specific gravity

White blood cells

Red blood cells

Bacteria

Crystals

Ketone (Acetoacetic acid)

Bilirubin

Proteins

Sugar

Sodium (mEq/l)

Potassium (mEq/l)

Chlorides (mEq/l)

Urinary anion gap

Bicarbonate (mEq/l)

Fractional excretion of bicarbonate (%)

Citrate

Amino acids

Calcium (mEq/l)

Novel Biomarkers

Cystatin C

Beta2-microglobulin

Retinol-binding protein

NGAL (Neutrophil gelatinase-associated lipocalin)

Kidney injury molecule 1 (KIM-1)

L-type fatty acid-binding protein (L-FABP)

FGF23 (Fibroblast growth factor 23), and beta-trace protein)

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)

Non-HDL-C (mg/dl)

VLDL-C (mg/dl)

Triglycerides (TG) (mg/dl)

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Patient {{ $iPatientNo }}

REDORA III

Doctor’s Details

Patient’s Details

General Examination Findings

CKD management Agents Utilization

Anti-Hypertensive Agents Utilization *

Antidiabetic Agents Utilization *

Investigations

Renal Profile

Renal Investigation Profile: (which ever data is available)

Urine (which ever data is available)

Novel Biomarkers

Glycemic Profile

Lipid Profile