DigiCon

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

Name of Doctor *

@else

Name of Doctor *

@endif {{--

Name of Doctor *

--}}

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

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

Heart Failure *

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

New York Heart Association (NYHA) functional class *

Class I Class II Class III Class IV

Number of re-hospitalization with current anti-heart failure medication therapy up to 1 year *

Number of visit to emergency department of hospital with current anti-heart failure medications therapy up to 1 year *

Type 2 Diabetes Mellitus*

Yes No

Hypertension *

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

History of Coronary Artery Disease (CAD) *

Yes No

History of Valvular Heart Disease *

Yes No

History of Congenital Heart Disease *

Yes No

History of Myocardial Infarction *

Yes No

History of Arrhythmia *

Yes No

Heart Failure Specific drug regimen*

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

Lipid Lowering 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

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

Anti Diabetic Drug 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

Any other Drug 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

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)

Heart Failure specific bio markers

NT-pro BNP

Others if any

2D ECHO

Cardiac MRI (Magnetic Resonance Imaging)

Exercise Stress Test *

Holter Monitoring *

Doppler Ultrasound*

Chest X-ray *

Pulmonary Function Tests *

Coronary Angiography *

Thyroid function tests: (if available)

Complete blood count (CBC) Platelets * WBC count * Basophils * Eosinophils * Lymphocytes * Monocyte * Neutrophils * Red blood cells * Hemoglobin * MCV * HCT * Hematocrit * MCH * Red blood cell indices *	Renal function tests Blood urea * Creatinine * Calcium * Potassium * Uric acid * Chloride * Estimated GFR * Phosphorus* Urinalysis * Albumin * Albumin to creatinine ratio * Sodium * Glucose *

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Patient {{ $iPatientNo }}

INDO HF 2

Doctor’s Details

Patient’s Details

General Examination Findings

Heart Failure Specific drug regimen*

Anti-Hypertensive Therapy Details *

Lipid Lowering Therapy Details *

Anti-platelet / Aspirin Therapy Details *

Anti Diabetic Drug Therapy Details *

Any other Drug Therapy Details

Investigations

Glycemic Profile

Lipid Profile

Heart Failure specific bio markers

2D ECHO