Digital Contract

@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 *

Diagnosis: Chronic Spontaneous Urticaria *

General Examination Findings

Pulse (per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in kg) *

Height (in cm) *

Body Mass Index (BMI)(kg/m²) *

Chronic spontaneous urticaria: Duration *

6-8 weeks 9-16 weeks 17-24 weeks >24 weeks

Family History *

Not Applicable (N/A) Past or current H/O CSU in family members Any Other

H/O co-morbidities * Diabetes

Yes No

Hypertension

Yes No

Liver impairment

Yes No

H/O treatment taken for the current condition (if any) Second generation non-sedative antihistamine

Yes No Other

First generation antihistamine

Yes No Other

H2 receptor antagonist

Yes No Other

Any other medications

Yes No Other

Second generation non-sedative anti-histamine given *

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

H2 receptor antagonist given *

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

Leukotriene receptor antagonist (if prescribed)

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

Other medications prescribed

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

CBC	Date of report
CRP	Date of report
IgE	Date of report
IgG anti-TPO	Date of report

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Teczine 5

Doctor’s Details

Patient’s Details

Diagnosis: Chronic Spontaneous Urticaria *

General Examination Findings

Second generation non-sedative anti-histamine given *

H2 receptor antagonist given *

Leukotriene receptor antagonist (if prescribed)

Other medications prescribed

Investigations (if available)

Any other investigation done. If yes