Friday, November 2, 2018

Structured proforma for an open labeled non randomized pilot trial to study diabetes patient outcomes


Name:                                   Age:         Gender:           
   contact no:                                    Address:
Heart rate:                  Weight:           kgs       Height:             cms                    BMI:
Diagnosis: Type 2 Diabetes mellitus since _____________ yrs.
Co-morbidities: Hypertension               hyper/ hypo thyroidism
Current complains:         
Pictures taken (if needed):                               consent taken :                    stored in :
Current medication:
S.no
medication
dose
route
frequency
1




2




3




4




5




Weekly evalauation data:
S.no
parameters
week
1st
2ND
3RD
4TH
5TH
6TH
1
Weight(kgs)






2
BMI






3
FBS






4
PPBS






5
BLOOD PRESSURE






6
EXERCISE






7
FOOD (CALORIE)







S.no
parameters
week
7Th
8Th
9Th
10Th
11Th
12Th
1
Weight(kgs)






2
BMI






3
FBS






4
PPBS






5
BLOOD PRESSURE






6
EXERCISE






7
FOOD (CALORIE)






S.no
Blood and urine Test
Baseline values
After the study/3months
Difference(%)
1
HbA1c



2
Fasting blood sugar



3
Blood urea nitrogen



4
Serum creatinine



5
TSH



6
Serum electrolytes



A)
Sodium(Na+)



B)
Potassium(K+)



C)
Chloride(Cl+)



D)
Calcium (Ca++)



E)
Magnesium(Mg++)



7
Fasting lipid profile



A)
LDL



B)
VLDL



C)
HDL



D)
TG



E)
T Chl



8
Urine sugar



9
Urine microalbumin



10
Urine ketones



11
Urine Creatinine









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