DigiCon

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@csrf

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

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Patient {{ $iPatientNo }}

(Kindly fill in the relevant information or tick, as appropriate.)

Doctor’s Details

@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

General Examination Findings

Pulse (per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in Kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

Heart failure 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

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

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

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
		OD BID TID

Anti-thrombotic 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

Life Style Modification

Recommendation given (Check applicable)	Type of advice given (Check applicable)	Adherence observed in the patient (Check applicable)
Diet	Switch to Low Glycemic Index Foods Low sodium diet Calorie restricted diet Referred to Dietician counselling Meal Replacement therapy Other	Compliant Non-compliant
Physical Activity	Walking Strength & conditional training exercise programs	Compliant Non-compliant
Behavioural Changes	Smoking cessation recommended Tobacco cessation recommended Alcohol cessation recommended Referred to structured programs	Compliant Non-compliant
*Compliant: 75% Adherence to the lifestyle modification advice

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) *

Renal Profile:

Serum Creatinine (mg/dl)

Urine Albumin (mg/dl)

e-GFR (ml/min/1.73 m²)

Serum uric acid (mg/dl)

Peak Trop - T Positive Negative	Peak Trop – I Positive Negative
BNP pg/ml	NT pro BNP pg/ml
ECG Rhythm SR AF Paced IVCD	QRS Complex Normal LBBB RBBB IVCD
Echo– EF%*
LV diastolic dysfunction No Mild Moderate Severe	MR No Mild Moderate Severe
Echo – any other descriptive finding If any other, please specify
TSH / HbA1c If any other, please specify