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Patient Details
Name
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Age
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Gender
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--Select--
Male
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Education
Occupation
State
Address
Presenting Complaints
Symptomatic since
*
--Select--
Birth
Infancy
Childhood
Adolescent
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Fat loss
*
--Select--
Generalized
Upper Body
Upper Extremity
Lower Extremity
Excessive appetite/ Hyperphagia
--Select--
Yes
No
Hyper pigmentation
--Select--
Yes
No
Premature aging
--Select--
Yes
No
Oligomenorrhea
--Select--
Yes
No
Hirsutism
--Select--
Yes
No
Infertility
--Select--
Yes
No
Muscle prominent
--Select--
Yes
No
Prominent veins
--Select--
Yes
No
Drug H/O
HIV
--Select--
Yes
No
Any autoimmune disease
Birth History
Consanguinity
--Select--
Yes
No
Inheritance
--Select--
Autosomal Dominant
Autosomal Recessive
Acquired
GENERAL EXAMINATION
Height in cm
Weight in kg
BMI
Waist Circumference
Absence of Body fat
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--Select--
Generalized
Upper limb
Lower limb
Buttocks
Hips
Fat Accumulation
--Select--
Buttocks
Hips
Prominent Muscles
--Select--
Yes
No
Acanthosis Nigricans
--Select--
Yes
No
Phlebomegaly
--Select--
Yes
No
Progeroid features
--Select--
Yes
No
Cushingoid or acromegaloid appearance
--Select--
Yes
No
Attach Clinical Photos (JPEG)
Attach Image(Jpeg/PDF)1
*
Attach Image(Jpeg/PDF)2
Attach Image(Jpeg/PDF)3
Attach Image(Jpeg/PDF)4
Biochemical Investigations:
FBS in mg/dL
PPBS in mg/dL
RBS in mg/dL
HBA1c in %
HOMA-IR or fasting Insulin
Urea mg/dL
Creatinine mg/dL
Urine Albumin
Spot Urine ACR / PCR mg/dL
24 hours urine protein creatinine ratio
C3 Compliment level
AST IU/L
ALT IU/L
LIPID PROFILE
Total cholesterol mg/dL
Triglycerides mg/dL
HDL mg/dL
LDL mg/dL
VLDL mg/dL
HORMONAL PROFILE
LH mIU/ml
FSH mIU/ml
Estradiol pg/ml
TSH μIU/mL
T4 μg/dL
Free T4 ng /dl
Serum Leptin levels
GAD 65 Antibody Levels IU/ml
DEXA Scan / Body Fat %
Total Body %
Right Arm %
Left Arm %
Right Leg %
Left Leg %
Trunk %
USG / MRI Image
Image(Jpeg/PDF)1
Image(Jpeg/PDF)2
Image(Jpeg/PDF)3
Image(Jpeg/PDF)4
USG/ MRI scan abdomen and pelvis
Fatty Liver
--Select--
Yes
No
Cirrhosis
--Select--
Yes
No
PCOS
--Select--
Yes
No
Liver Biopsy
Final Diagnosis
Final Diagnosis
*
--Select--
Acquired
Autosomal dominant
Autosomal recessive
Complete Diagnosis
Treatment Received
Insulin requirement units
Other anti-diabetic drugs (Pioglitazone, Metformin, SGLT2i)
Genetic Report
Attach Genetic Report (Jpeg/PDF)
Complications
Cardiomyopathy
--Select--
Yes
No
Heart failure
--Select--
Yes
No
Arrhythmias
--Select--
Yes
No
Myocardial Infarction
--Select--
Yes
No
Liver disease
--Select--
Yes
No
Kidney failure
--Select--
Yes
No
Acute Pancreatitis
--Select--
Yes
No
Malignancy / Lymphomas
--Select--
Yes
No
