DigiCon

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Case Report Form

Doctor’s Details

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

Name *

@else

Name *

@endif

Registration No. *

Qualification *

Speciality *

Hospital/Clinic Address *

City *

State *

Patient’s Details

Initials *

Gender *

Male Female

Diagnosis: (please mention duration wherever applicable)

Co-morbid condition/s if any:
Cardiovascular diseases
Diabetes or any other endocrinological disease
Neuropsychiatric disease
Any other disease

General Examination Findings

Weight (in Kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

Tick any one of the below *

Underweight Healthy weight Overweight Obese Any other

Pulse (Per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Stool form on Bristol Stool Chart *

Treatment *

Drug Class and Drug (generic name only)	Dose/Strength (in mg unless specified)	Frequency of dosing	Duration of treatment (in months)
VSL# 3		OD BID TID
Concomitant drugs, if any
		OD BID TID
		OD BID TID
		OD BID TID
		OD BID TID
		OD BID TID

Investigations

Complete blood count*

CRP*

Blood sugar *

TSH *

Stool microscopy*

Fecal calprotectin (if done)

USG report (if available)

Colonoscopy report (if done)

Colonic transit time study/ anorectal manometry report (if done)

Reports of Breath tests for small intestinal bacterial overgrowth (if done)

Any other laboratory tests/ imaging tests done (please mention if applicable)