DigiCon

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Patient {{ $iPatientNo }}

Data Collection Form (DCF)

Doctor’s Details

Name of Doctor *

Registration No. *

Qualification *

Speciality * {{-- --}}

Hospital/Clinic Address *

City *

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State *

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State *

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Patient’s Details

Initials *

OPD/IPD Registration No *

Gender *

Male Female

General Examination Findings

Heart failure 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

Anti- Diabetic 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-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

Life Style Modification *

Recommendation given (Check applicable)	Type of advice given (Check applicable)	Adherence observed in the patient (Check applicable)
Diet	Switch to Low Glycemic Index Foods Low sodium diet Calorie restricted diet Referred to Dietician counselling Meal Replacement therapy Other	Compliant Non-compliant
Physical Activity	Walking Strength & conditional training exercise programs	Compliant Non-compliant
Behavioural Changes	Smoking cessation recommended Tobacco cessation recommended Alcohol cessation recommended Referred to structured programs	Compliant Non-compliant
*Compliant: 75% Adherence to the lifestyle modification advice

Investigations

Heart Failure specific bio markers

BNP (pg/ml)

NT pro BNP (pg/ml)

Others if any

ECG Rhythm*	QRS Complex*
SR AF Paced IVCD	Normal LBBB RBBB IVCD
Echo – EF (%)

LV diastolic dysfunction*	MR*
No Mild Moderate Severe	No Mild Moderate Severe
Echo – any other descriptive finding
Any Other investigation specify (E.g. TSH)

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) *

Renal Profile:

Serum Creatinine (mg/dl)

Urine Albumin (mg/dl)

e-GFR (ml/min/1.73 m²)

Serum uric acid (mg/dl)