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Patient Data Collection for Diabetes Study

This document appears to be a data collection form for a study on the therapeutic management of diabetes complications in rural patients. It collects information such as patient name, age, health details, family history, current complications, treatment regimen including medication and insulin administration, adherence, blood sugar levels, and types of oral drugs and insulin used. The goal is to understand treatment and management of diabetes and related issues in rural areas.

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Prasanth Prasanth
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61 views2 pages

Patient Data Collection for Diabetes Study

This document appears to be a data collection form for a study on the therapeutic management of diabetes complications in rural patients. It collects information such as patient name, age, health details, family history, current complications, treatment regimen including medication and insulin administration, adherence, blood sugar levels, and types of oral drugs and insulin used. The goal is to understand treatment and management of diabetes and related issues in rural areas.

Uploaded by

Prasanth Prasanth
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

ANNAI JKKMRF”S SAMpooRANI AMMAl college oF phARMAcy- Komarapalayam

A survey study on therapeutic management of complication


Status in patient with diabetic mellitus in
rural areas of namakkal district
data collection form

Case no: Date:

Patient name: Age: sex: male / female

Height : weight: BP:

Type of diabetes mellitus: Type 1 Type 2 gestational

[Link]
Family history: disease
[Link]
Co-morbidity: [Link]
[Link]
Complication: [Link]
eye foot UTI KIDNEY NERVE Ear heart CNS
[Link]
[Link]
Diabetes mellitus theraphy:
Cost of therapy patient perception:
High low moderate
Adherence:
Missed dose Not correct time Self increasing dose No time to checkup

Refill:
before tablet over After tablet over More than 2 days over

Daily activity(exercise:walking): mild \ moderate.

Genetic disorder: Yes / No


ANNAI JKKMRF”S SAMpooRANI AMMAl college oF phARMAcy- Komarapalayam

Blood sugar tests:

FBS : [3.9 to 5.4 mmols/l] (70 to 99mg/dl)


RBS : [4.4-8.9 mmol/l](80-130mg/dl)
PPBS: [5-7.2mmol/l] (90-130mg/dl)
HBA1C:

Types of treatment:

[Link]: yes /no


[Link]: yes /no
[Link]: yes/no

Insulin administration: injection / pen

How many times you use insulin injection: OD/bd/tds

Insulin injection:
Rapid acting.
short-acting
long-acting
intermediate-acting
Oral drug:
1. sulfonylureas tolbutamide glibenclamide glipizide gliclazide glimepiride
2. Meglitidine/phenylalanine repaglinide Nateglinide
analogues
3. GLP-1(injectable drugs) Exenatide liraglutide
4. DPP4-4 inhibitors Sitagliptin Vildagliptin Algogliptin linagliptin Saxagliptin
Algogliptin
5. Biguanide(AMPk activator metformin PPARγ pioglitazone
activitaor
6. Glucosidase inhibitors acarbose miglitol voglibose
7. Amylin analogue Pramlintide
8. Dopamine D2 receptor bromocriptin
9. SGLT-2 inhibitor dapaglifloxine

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