Digital Contract

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

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

Logout

@endif

{{ $ActivityName }}

{{--

--}}

@csrf

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

Back

@else

@endif

Patient {{ $iPatientNo }}

AMPLIFY II 24-25

Data Collection Form (DCF)

Doctor’s Details

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

Name of Doctor *

@else

Name of Doctor *

@endif

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

General Examination Findings

Anti-Diabetic Therapy Details*

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

Lipid Lowering 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
		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

Weight loss / Anti Obesity Drugs if any

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 Diabetes Specific Nutrition Supplement 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

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)

{{ $ActivityTypeName }}

{{ $ActivityTypeName }}

Patient {{ $iPatientNo }}

AMPLIFY II 24-25

Doctor’s Details

Patient’s Details

General Examination Findings

Anti-Diabetic Therapy Details*

Anti-Hypertensive Therapy Details *

Lipid Lowering Therapy Details *

Anti-platelet / Aspirin Therapy Details *

Weight loss / Anti Obesity Drugs if any

Life Style Modification *

Investigations

Glycemic Profile

Lipid Profile

Renal Profile