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Vital Signs

ParameterNormalRange

Date

D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13D14

BP120/80mmHg

Temp 37.2C

RR 12-18 bpm

PR 60-100 bpm

Full Blood Count

Parameter

Referencerange

DateRef Range

HTAA1 2 3 4 5 6 7 8 9 10 1112

13 14

WBC4.5

11.0x109/L4.0-10x109/L

RBC 4-4.9 x1011/L 4.5- 6.5x1012/L

Hb12.0

15.0g/dL13-17 g/dL

HCT 36 44%150-450x109/L

Plt

150

450x109/L 40-50%

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Renal Profile

Parameter

Referencerange

Date Ref RangeHTAA1 2 3 4 5 6 7 8 9 10 11 12 13 14

BUN

2.5 -7.5

mmol/L 2.8 7.2

sodium133-148mmol/L

136 146

potassium

3.5-5.1mmol/L

3.5 5.1

chloride95-108mmol/L

98 106

Creatinine

44-133mol/L

59 104

Creatinine

Clerance

105-150ml/min

105 150

where Constant is 1.23 for men and 1.04 for women

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Ideal Body Weight (IBW) or Lean Body Weight(LBW)Males: IBW = 50 kg + 2.3 kg for each inch over 5 feetFemales: IBW = 45.5 kg + 2.3 kg for each inch over 5feet

* 1 ft = 12 inch.5 ft = 60 inch.

Use Total Body Weight (TBW) ifTBW < LBW

Use Adjusted Body Weight (ABW) ifobese > 125%of LBW

Adjusted Body WeightABW = LBW + 0.4 (actual weight - LBW)

Liver Profile

Parameter

Referencerange

Date Ref RangeHTAA1 2 3 4 5 6 7 8 9 10 11 12 13 14

Albumin 35-50 g/L 35 52

TotalBilirubin

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Cardiac Enzymes

ParameterReference

RangeUnit

Date

1 2 3 4 5 6

CK 24-195 u/L

LDH 0-248 u/L

AAT < 37

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Coagulation Profile

ParameterReference

RangeUnit

Date

1 2 3 4 5 6

PT 10-13.5 Sec

APTT 26-42 Sec

INR < 1.5

Lipid Profile

ParameterReference

RangeUnit

Date

1 2 3 4 5 6 7

T-Chol 1.7 mmol/L

C-LDL < 3.9 mmol/L

Others

ParameterReference

RangeUnit

Date

RBS < 11.0 mmol/LHb1AC 4.0-6.0 mmol/L

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Blood Sugar Monitoring Chart

Normal FBS: 3.9-5.5 mmol/L

Normal RBS: < 7.8 mmol/L

Date TimeMeasurement

(mmol/L)Date Time

Measurement(mmol/L)

Date TimeMeasurement

(mmol/L)

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COMPLIANCE ASSESSMENT(Choose either A or B)

A. i) Patients Report(Morisky Scale)

No. QUESTIONSYES 1

NO - 0

1 Do you ever forget to take your medications?

2Are you careless at times about taking your medications?

(Do you sometimes miss a dose?)

3When you feel better, do you sometimes stop taking your

medications?

4Sometimes if you feel worse when you take your

medications, do you stop taking them?

SCORE

* Compliant score indicator:

(4) noncompliant; (3) poor; (2) average; (1) satisfactory; (0) compliant

ii) Other relevant questions (optional) Yes No

1. Does the patient take full responsibility for his/her medicationadministration or is he/she assisted by someone else?

2. Does patient understand reason for taking medication?

3. Does patient ever use someone elses medication?

4. Does patient ever share medication with anyone else?

5. Does patient normally bring along medication with him/her?

6. Does patient worry about side effects of his/her medication?

7. What does patient do if a dose is missed? ________________________________________

__________________________________________________________________________

8. Under what circumstances and how frequently are doses missed? _____________________

__________________________________________________________________________

9. How are the medications stored? _______________________________________________

_______________________________________________________________________