DigiCon

@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

Smoker *

Current Former Never

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) *

History, Co-existing diseases and concomitant therapies

(Please tick more than one options if needed as appropriate)

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

Dyslipidemia disease characteristics and Concomitant therapies

Years since Dyslipidemia diagnosis*

Less than 1 years 1 to <2 years 2 to <3 years 3 to <4 years 4 to <5 years 5 to <10 years ≥10 years

Therapy *

Given Not Given

If given, Select appropriate option

Single Drug Multiple Drug Multiple drug as FDC

Statin Utilization *

(Please tick more than one options if needed as appropriate)

Drug	Dose/Strength (in mg unless specified)	Duration
Rosuvastatin	5 10 20 40	<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 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

HbA1c (%)*

Fasting Plasma Glucose (mg/dl)

Post-prandial Plasma Glucose (mg/dl)

Renal Profile

Serum Creatinine (mg/dl)

Urine Albumin (mg/L)

e-GFR

Coronary imaging *

Done Not Done

If done

Coronary Angiography CT Angiography

If Yes, Findings

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MORE-CV Study - Data Collection Form (DCF)

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*

Lipid Profile

Glycemic Profile

Renal Profile