Digicon

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

Back

@else

@endif

Patient {{ $iPatientNo }}

(Kindly fill in the relevant information or tick, as appropriate.)

Doctor’s Details

@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

General Examination Findings

Heart Rate / Pulse (Per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

Details of Ticagrelor given in last 12 months
Drug	Drug administered	Pre procedure Loading dose if given (in mg unless specified)	Maintenance dose given (in mg unless specified)	Frequency of dosing	Duration in months
Ticagrelor	Yes No			OD BID	3m 6m ≥12m

Whether Ticagrelor was stopped and switched in last 12 months

Yes No

If YES, kindly tick appropriate reasons mentioned below

Affordability Convenience High bleeding risk Any other

Any Thrombotic events while on Ticagrelor

Yes No

Any Bleeding events observed while on Ticagrelor

Yes No

If yes please specify

Major Minor

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)

Blood Urea Nitrogen (mg/dl)

Serum uric acid (mg/dl)

{{ $ActivityTypeName }}

Patient {{ $iPatientNo }}

Doctor’s Details

Patient’s Details

General Examination Findings

History, Co-existing diseases and Concomitant therapies

(Please tick more than one options if needed as appropriate)

Acute Coronary Syndrome (ACS) disease characteristics, and Concomitant therapies

(Please tick more than one options if needed as appropriate)

Investigations