Digital Contract

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

Back

@else

@endif

Patient {{ $iPatientNo }}

BEAT CVD

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

Age (in Years) *

City/Town *

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

State *

@else

State *

@endif

H/O Alcohol consumption *

Yes No

Smoker *

Current Former Never

If Former, How long ago did patient quit smoking?

Unknown <6 months ago 6 months–1.5 years ago >1.5–2.5 years ago >2.5–3.5 years ago >3.5–5 years ago >5 years ago

General Examination Findings

Pulse (per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in Kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

Tick any one of the below *

Overweight Obese

Type 2 Diabetes Mellitus: Years since diagnosis: *

Less than 1 yr 1 to <5 yrs 5 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

Dyslipidemia *

Yes No

If Yes, Years since diagnosis

Less than 1 yr 1 to <5 yrs 5 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

If Yes, whether taking lipid lowering drugs

Yes No

History of Chronic Kidney Disease (CKD) *

Yes No

History of Coronary Artery Disease (CAD) *

Yes No

History of Stroke *

Yes No

Peripheral vascular disease *

Yes No

If Yes, Years since diagnosis

Less than 1 yr 1 to <5 yrs 5 to <10 yrs 10 to <15 yrs 15 to <20 yrs ≥20 yrs

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

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

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) *

Non-HDL (mg/dl) *