Digicon

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Name of Doctor*

@else

Name of Doctor *

@endif

Registration No. *

Qualification *

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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 *

H/O Alcohol consumption: *

Yes No

Smoker *

Yes No

General Examination Findings

Pulse (per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

History, Co-existing diseases and Disease characteristics

Family History *

Not Applicable (N/A)

Diabetes

Hypertension

Dyslipidemia

Coronary Artery Disease

Cerebrovascular Disease

Chronic Kidney Disease

Heart Failure

Any other (Please specify)

Diagnosis:

Dyslipidemia

Years since diagnosis:

Less than 1 yr 1 to <2 yrs 2 to <3 yrs 3 to <4 yrs 4 to <5 yrs 5 to <10 yrs ≥10 yrs

CAD

Years since diagnosis:

Less than 1 yr 1 to <2 yrs 2 to <3 yrs 3 to <4 yrs 4 to <5 yrs 5 to <10 yrs ≥10 yrs

Hypertension

Years since diagnosis:

Less than 1 yr 1 to <2 yrs 2 to <3 yrs 3 to <4 yrs 4 to <5 yrs 5 to <10 yrs ≥10 yrs

Comorbid conditions

Yes No

If Yes, provide following details

Diabetes Heart failure PAD Cerebrovascular Disease Chronic Kidney Disease Any other

Dyslipidemia Treatment Details

Drug	Dose/Strength (in mg)	Frequency of dosing	Start Date	Stop Date (If stopped)
Rosuvastatin	5 10 20 40	OD BID TID

Concomitant drugs, if any

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

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

Lipid Profile:*

Total Cholesterol (mg/dl) *

LDL-C (mg/dl) *

HDL-C (mg/dl) *

VLDL-C (mg/dl)

Triglycerides (TG) (mg/dl) *

Apo B (mg/dl)

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Patient {{ $iPatientNo }}

Doctor’s Details

Patient’s Details

General Examination Findings

History, Co-existing diseases and Disease characteristics

Dyslipidemia Treatment Details