DigiCon

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

Back

@else

@endif

Patient {{ $iPatientNo }}

AXCEMI

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

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	3 months 6 months 6-12 months ≥12 months

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

(TIMI definition)

Major: any intracranial bleeding (excluding microhemorrhages of less than 10 mm evident only on gradient-echo magnetic resonance imaging); clinically overt signs of haemorrhage associated with a drop in haemoglobin of 5 g/dL or greater; fatal bleeding (bleeding that directly results in death within seven days).

Minor: clinically overt (including imaging), resulting in a haemoglobin drop of 3 g/dL to less than 5 g/dL.

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 }}

AXCEMI

Doctor’s Details

Patient’s Details

General Examination Findings

History, Co-existing diseases and Concomitant therapies

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

Details of Ticagrelor given in last 12 months *

(TIMI definition)

Investigations

Glycemic Profile:

Lipid Profile:

Renal Profile: