Digital Contract

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

Back

@else

@endif

Data Collection Form (DCF)

@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

Initials *

OPD/IPD Registration No *

Gender *

Male Female

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

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

HbA1c (%)*

Fasting Plasma Glucose (mg/dl)*

Post-prandial Plasma Glucose (mg/dl) *

Total Cholesterol (mg/dl) *

LDL-C (mg/dl) *

HDL-C (mg/dl) *

VLDL-C (mg/dl) *

Triglycerides (TG) (mg/dl) *

Serum Creatinine (mg/dl)

Urine Albumin (mg/dl)

e-GFR (ml/min/1.73 m²)

Serum uric acid (mg/dl)