DESMOND Patient Data Collection Form Patient Name:
Date measure taken (dd/mm/yy): HbA1c (%):
BP (mmHg): Systolic
Total Cholesterol (mmol/l):
BP (mmHg): Diastolic
HDL (mmol/l):
Weight (kg): without shoes
LDL (mmol/l):
Height (cm): without shoes
Triglyceride (mmol/l):
Waist (cm):
Mark ‘X’ in the box if NOT fasting
Is the patient currently taking one of the following? Yes Medication Type
Tick (�)
No
If yes, please give details
Name of Medication
Dose
ACE – Inhibitor Alpha Blocker ARB Beta-blockers Calcium Channel Blockers Diuretics/Thiazides Aspirin Lipid Lowering – Statin Lipid Lowering – Fibrate Metformin Sulphonylurea Glitazone Prandial Glucose Regulator Steroids Please state whether Steroids are oral, injected or inhaled:
Oral
Injected
Inhaled
Please return this form to your local DESMOND Team:
© The DESMOND Collaborative 2006
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