DigiCon

@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

H/O Alcohol consumption:

Yes No

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

Hypertension: 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

History of Chronic Kidney Disease (CKD)

Yes No

Anti-platelet / Aspirin Therapy initiated

Yes No

If No, specify the reason;

If Yes, duration of therapy;

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

Anti-Hypertensive 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-platelet / Aspirin 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
Other concomitant medications details with dosage and durations (if any)

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)

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Patient {{ $iPatientNo }}

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

Investigations

Glycemic Profile:

Lipid Profile: