DigiCon

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

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

Logout

@endif

@csrf

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

Back

@else

@endif

Patient {{ $iPatientNo }}

ROSULEAD-III

Data Collection Form (DCF)

Doctor’s Details

Name of Doctor *

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

Smoker *

Yes No

H/O Alcohol consumption: *

Yes No

General Examination Findings

Dyslipidemia Treatment Details*

Drug	Dose/Strength (in mg)	Frequency of dosing
Rosuvastatin	5 10 20 40	OD BID TID
Concomitant drugs, if any
	5 10 20 40	OD BID TID

Anti-diabetic therapy*

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

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
		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) *

Glycemic Profile

HbA1c (%)

FBG (mg/dl)

PPBG (mg/dl)

Renal Profile:

Serum Creatinine (mg/dl)

e-GFR (ml/min/1.73 m²)

Blood Urea Nitrogen

{{ $ActivityTypeName }}

Patient {{ $iPatientNo }}

ROSULEAD-III

Doctor’s Details

Patient’s Details

General Examination Findings

History, Co-existing diseases and Disease characteristics

Dyslipidemia Treatment Details*

Anti-diabetic therapy*

Anti-platelet / Aspirin Therapy Details*

Investigations

Lipid Profile

Glycemic Profile

Renal Profile: