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

1.cardiovascular
Family history: disease
2.cancer
Co-morbidity: 3.hypertension
4.liver
Complication: 5.kidney
eye foot UTI KIDNEY NERVE Ear heart CNS
6.dysphagia
7.others
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:

1.oral: yes /no

2.insulin: yes /no
3.both: 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