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

General Examination Findings

Pulse(per minute) *

Blood Pressure: Systolic (mmHg) *

Diastolic (mmHg) *

Weight (in Kg) *

Height (in cm) *

Body Mass Index (BMI) (kg/m²) *

Tick any one of the below*

Overweight Obese

Family History *

Not Applicable (N/A)

Diabetes

Hypertension

Dyslipidemia

Coronary Artery Disease

Cerebrovascular Disease

Chronic Kidney Disease

Heart Failure

Any other

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

History of Chronic Kidney Disease (CKD)

Yes No

If Yes, Stage of CKD

Stage I Stage II Stage III Stage IV Stage V

History of Coronary Artery Disease (CAD) *

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

Antidiabetic Agents Utilization

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

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

CKD specific medications

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

Renal Profile: *

Serum Creatinine (mg/dl)*

Urine Albumin (mg/dl)*

e-GFR (ml/min/1.73 m²) *

Serum uric acid (mg/dl) *

Glycemic Profile*

HbA1c (%)*

Fasting Plasma Glucose (mg/dl)*

Post-prandial Plasma Glucose (mg/dl)*

Lipid Profile (If Done):

Total Cholesterol (mg/dl)

LDL-C (mg/dl)

HDL-C (mg/dl)

VLDL-C (mg/dl)

Triglycerides (TG) (mg/dl)

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Patient {{ $iPatientNo }}

Doctor’s Details

Patient’s Details

General Examination Findings

Antidiabetic Agents Utilization

Anti-Hypertensive Therapy Details

CKD specific medications

Investigations