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 *

State *

H/O Alcohol consumption: *

Yes No

Smoker *

Current Former Never

General Examination Findings

Pulse(per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in Kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

History, Co-existing diseases and Concomitant therapies

Family History *

Not Applicable (N/A)

Diabetes

Hypertension

Dyslipidemia

Coronary Artery Disease

Cerebrovascular Disease

Chronic Kidney Disease

Heart Failure

Any other

History of Acute Coronary Syndrome (ACS) *

Yes No

History of Myocardial Infarction (MI) *

Yes No

History of Transient Ischemic Attack (TIA) *

Yes No

Coronary Intervention done *

Yes No

If Yes, Type of Intervention

Percutaneous coronary Intervention (PCI) Coronary artery bypass graft (CABG)

History of Ischemic stroke *

Yes No

Symptomatic peripheral arterial disease*

Yes No

History of Chronic Kidney Disease (CKD) *

Yes No

If Yes, Stage of CKD

Stage I Stage II Stage III Stage IV Stage V

Statin Utilization *

Drug	Dose/Strength (in mg unless specified)	Duration
Atorvastatin	5 10 20 30 40 80	<3 Month 3-6 Month 6-12 Month >12 Month
Rosuvastatin	5 10 20 40	<3 Month 3-6 Month 6-12 Month >12 Month
Fluvastatin	20 40 80	<3 Month 3-6 Month 6-12 Month >12 Month
Lovastatin	10 20 40 80	<3 Month 3-6 Month 6-12 Month >12 Month
Pravastatin	10 20 40 80	<3 Month 3-6 Month 6-12 Month >12 Month
Simvastatin	5 10 20 40 80	<3 Month 3-6 Month 6-12 Month >12 Month
Ezetimibe	10	<3 Month 3-6 Month 6-12 Month >12 Month
Fenofibrate	145 160 120 150	<3 Month 3-6 Month 6-12 Month >12 Month
Niacin	50 100 125 250 500 750 1000	<3 Month 3-6 Month 6-12 Month >12 Month
Alirocumab	75 mg/mL 150 mg/mL	<3 Month 3-6 Month 6-12 Month >12 Month
Evolocumab	140 mg/mL 420 mg/3.5 mL	<3 Month 3-6 Month 6-12 Month >12 Month

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

Investigations

Lipid Profile*

Total Cholesterol (mg/dL)*

LDL-C (mg/dL)*

HDL-C (mg/dL)*

VLDL-C (mg/dL)*

Triglycerides (TG) (mg/dL)*

Glycemic Profile : If done

HbA1c (%)

Fasting Plasma Glucose (mg/dl)

Post-prandial Plasma Glucose (mg/dl)

Renal Profile: If done

Serum Creatinine (mg/dl)

Urine Albumin (mg/dl)

e-GFR (ml/min/1.73 m²)

Coronary imaging*

Done Not Done

If done,

Coronary Angiography CT Angiography

If Yes,

Finding

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Patient {{ $iPatientNo }}

Doctor’s Details

Patient’s Details

General Examination Findings

History, Co-existing diseases and Concomitant therapies

Dyslipidemia disease characteristics and Concomitant therapies

Statin Utilization *

Anti-Diabetic Therapy Details

Investigations