Digital Contract

@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

If Former, How long ago did patient quit smoking? *

<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) *

Type 2 Diabetes Mellitus: 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

Family History *

Not Applicable (N/A)

Diabetes

Hypertension

Dyslipidemia

Coronary Artery Disease

Cerebrovascular Disease

Chronic Kidney Disease

Heart Failure

Any other

History of Chronic Kidney Disease (CKD) *

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

Anti-platelet / Aspirin Therapy initiated *

Yes No

If No, specify the reason *

If Yes, duration of therapy*

History of Coronary Artery Disease (CAD) *

Yes No

If Yes, History of Myocardial Infarction (MI):

Yes No

If Yes, Coronary Intervention done:

Yes No

If Yes, Type of Intervention:

Coronary Angioplasty Coronary artery bypass graft (CABG)

Cerebrovascular disease *

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

Peripheral vascular disease *

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

Anti-Diabetic Therapy Details

Drug Class and Drug (generic name only)	Dose/Strength (in mg unless specified)	Frequency of dosing
Sitagliptin	25 50 100	OD BID TID
Sitagliptin Metformin	50+500 50+1000	OD BID TID
Sitagliptin + Metformin XR	100+500 100+1000	OD BID TID
Sitagliptin + Dapagliflozin + Metformin XR	10+100+1000 10+100+500	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
		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
		OD BID TID
		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

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

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Patient {{ $iPatientNo }}

Doctor’s Details

Patient’s Details

General Examination Findings

Anti-Diabetic Therapy Details

Anti-Hypertensive Therapy Details

Lipid Lowering Therapy Details

Anti-platelet / Aspirin Therapy Details

Anti-thrombotic Therapy Details

Life Style Modification

Investigations