DigiCon

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

Name *

@else

Name *

@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 *

Smoker *

Yes No

H/O Atopic dermatitis/asthma *

Yes No

General Examination Findings

Pulse(minute)

Blood Pressure: Systolic(mmHg)

Diastolic(mmHg)

Weight(in Kg) *

Height(in cm) *

Body Mass Index (BMI)(kg/m²)

History, Co-existing diseases and Concomitant therapies

Family History *

Not Applicable (N/A)

Diabetes

Hypertension

Dyslipidemia

Coronary Artery Disease

Cerebrovascular Disease

Chronic Kidney Disease

Heart Failure

Any other

Diabetes disease characteristics, related complications and Concomitant therapies

Type 2 Diabetes Mellitus*

Years since diagnosis

Less than 1 yr 1 to < 2 yrs 2 to <3 yrs 3 to <4 yrs 4 to <5 yrs 5 to <10 yrs ≥10 yrs

Antidiabetic Agents Utilization

Drug Class and Drug*	Dose/Strength (in mg unless specified)*	Frequency of dosing*
Biguanides
Metformin IR XR	250 500 750 1000 500 850 1000	OD BID TID
Sulfonylureas & combinations
Glimepiride	0.5 1 2 3 4	OD BID TID
Glimepiride + Metformin	0.5/500 1/500 2/500 3/500 4/500 1/850 2/850 3/850 0.5/1000 1/1000 2/1000 4/1000 3/1000	OD BID TID
Glimepiride + Metformin + Voglibose	1/500/0.2 2/500/0.2 2/500/0.3 3/500/0.3	OD BID TID
Glimepiride + Metformin + Pioglitazone	1/500/15 2/500/15	OD BID TID
Gliclazide	20 30 40 60 80	OD BID TID
Gliclazide + Metformin	30/500 40/500 60/500 80/500	OD BID TID
Gliclazide + Metformin + Voglibose	40/500/0.3 80/500/0.2 80/500/0.3	OD BID TID
Gliclazide + Metformin + Pioglitazone	30/500/15 40/500/15 60/500/15 80/500/7.5 80/500/15	OD BID TID
Glipizide	2.5 5 10	OD BID TID
Glipizide + Metformin	2.5/250 5/500	OD BID TID
Thiazolidinedione (TZD) & combinations
Pioglitazone	7.5 15 30	OD BID TID
Pioglitazone + Metformin	7.5/500 15/500 30/500 15/1000	OD BID TID
Alpha glucosidase inhibitors (AGIs) & combinations
Voglibose	0.2 0.3	OD BID TID
Acarbose	25 50	OD BID TID
Voglibose + Metformin	25/500 50/500	OD BID TID
Acarbose + Metformin	0.2/500 0.3/500 25/500 50/500	OD BID TID
Meglitinides & combinations
Repaglinide	0.5 1 2	OD BID TID
Nateglinide	60 120	OD BID TID
Repaglinide + Metformin	1/500 2/500	OD BID TID
Nateglinide + Metformin	60/500 120/500	OD BID TID
Repaglinide + Voglibose	0.5/0.2 1/0.2 0.5/0.3 1/0.3	OD BID TID
Repaglinide + Metformin + Voglibose	0.5/500/0.3 1/500/0.3	OD BID TID
Dipeptidyl peptidase 4 (DPP-4) inhibitors & combinations
Vildagliptin	50 100	OD BID
Vildagliptin + Metformin	50/500 50/850 50/1000	OD BID
Sitagliptin	50 100	OD
Sitagliptin + Metformin	50/500 50/1000 100/10000	OD BID
Saxagliptin	2.5 5 10	OD
Saxagliptin + Metformin	5/500 5/1000	OD
Linagliptin	5	OD
Linagliptin + Metformin	2.5/500 5/500 2.5/850 2.5/1000	OD BID
Teneligliptin	20	OD
Teneligliptin + Metformin	20/500 20/1000	OD BID
Sodium-glucose cotransporter 2 inhibitors & combinations
Dapagliflozin	5 10	OD
Dapagliflozin + Metformin	5/500 5/1000 10/500 10/1000	OD
Empagliflozin	10 25	OD BID
Empagliflozin + Metformin	5/500 12.5/500 12.5/1000	OD BID
Canagliflozin	100 300	OD
Canagliflozin + Metformin	50/500 50/1000	OD BID
Remogliflozin	100	OD BID
Remogliflozin + Metformi	100/500 100/1000	OD BID
SGLT2i + DPP4i
Empagliflozin + Linagliptin	25/5 10/5	OD
Dapagliflozin + Saxagliptin	5/10	OD
Remogliflozin + Vildagliptin	100/50	OD BID
Remogliflozin + Teneligliptin	100/10	OD BID
Remogliflozin + Vildagliptin+ Metformin	100/50/1000	OD BID
Glucagon-like peptide 1 (GLP-1) receptor agonis
Liraglutide	0.6 1.2 1.8	OD
Lixisenatide	10 mcg 20 mcg	OD
Exenetide	5 mcg 10 mcg	BID
Dulaglutide	0.75 1.5	Once weekly
Insulin Therapy
Basal Insulin		OD BID
Bolus Insulin		OD BID
Premix Insulin		OD BID TID
Any Other (Please specify)		OD BID TID

Investigations

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)

PHDL-C (mg/dl)

VLDL-C (mg/dl)

Triglycerides (TG) : (mg/dl)

Renal Profile: If done

Serum Creatinine (mg/dl)

Urine Albumin (mg/L)

e-GFR (ml/min/1.73 m²)

Blood Urea Nitrogen

Albumin-to-Creatinine Ratio (ACR):

2D Echocardiography report: If done

Left ventricular ejection fraction (LVEF) value (%)

Ventricular hypertrophy

Yes No Any Other

CT Angiography conducted

Yes No Any Other

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Patient {{$iPatientNo}}

Doctor’s Details

Patient’s Details

General Examination Findings

History, Co-existing diseases and Concomitant therapies

Diabetes disease characteristics, related complications and Concomitant therapies

Microvascular Complications

Antidiabetic Agents Utilization

Investigations