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 *

H/O Alcohol consumption: *

Yes No

Smoker *

Current Former Never

If Former, How long ago did patient quit smoking?

Unknown 1.5-2.5 years ago >2.5-3.5 years ago >3.5-5 years ago >5 years ago

Family History *

Not Applicable (N/A) Diabetes Hypertension Dyslipidemia Cholestatic liver disease Any Other

Any relevant Drug History: Please mention if applicable

Diagnosis: (please mention duration wherever applicable)

Co-existing diagnosis if any: Please mention
Cardiovascular diseases
Diabetes or Any Other endocrinological disease
Neurological disease
Any Other disease

General Examination Findings

Weight (in Kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

Pulse (Per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Tick any one of the below *

Underweight Healthy weight Overweight Obese Any Other

Treatment *

Drug Class and Drug (generic name only)	Dose/Strength (in mg unless specified)	Frequency of dosing	Duration of treatment (in months)
Ursodeoxycholic acid		OD BID TID
Concomitant drugs, if any
		OD BID TID
		OD BID TID
		OD BID TID
		OD BID TID
		OD BID TID

Investigations

Liver profile

Serum total bilirubin (mg/dL)*

Serum Direct bilirubin (mg/dl)*

Serum Indirect Bilirubin (mg/dl) *

Alkaline phosphatase (U/L) *

Gamma-glutamyl transferase (GGT) (U/L) *

Alanine transaminase (ALT) (U/L) *

Aspartate transaminase (AST) (U/L) *

Lactate dehydrogenase (AST) (U/L) *

Total Protein (g/dL) *

Albumin (g/dL) *

Globulin (g/dL) *

A/G ratio *

international normalized ratio of prothrombin time *

Lipid Profile

Total Cholesterol (mg/dl) *

LDL-C (mg/dl) *

HDL-C (mg/dl) *

VLDL-C (mg/dl) *

Triglycerides (TG) (mg/dl) *

Non-HDL (mg/dl) *

Complete blood count *

USG report (if available)

CT scan report (if done)

Any Other laboratory tests/ imaging tests done (please mention if applicable)

{{ $ActivityTypeName }}

Case Report Form

Doctor’s Details

Patient’s Details

Diagnosis: (please mention duration wherever applicable)

General Examination Findings

Treatment *

Investigations

Liver profile