Neonatal and Maturity onset of youth registry india
 
   
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NEONATAL AND MONGENIC DIABETES RESGISTRY INDIA

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Neonatal Diabetes Registry
MODY Diabetes Registry
Doctor Registration Form
Neonatal Registration Form
MODY Registration Form
Consent Form
How to Send The Blood Sample
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Maturity Onset Diabetes of the Young (MODY)
   
Patient Name
Gender  
Date Of Birth                            
Age
M.No  
Contact Address
City  
State
Pincode
Clinical information     
Age at diagnosis *      
Diagnosed during pregnancy
Ethnic origin      
BMI
Height (cms)*      
Weight (kg)*    
Current therapy: Is patient treated with      
Diabetic complications if any    
Deafness
Renal cysts
Proteinuria
Renal failure
Low renal threshold for glucose
Most recent FBG or OGTT result
FBG (0HR)
2 HRS
Date(FBG)
Highest FBG or PPBG or 2 hr OGTT result (if available):
Date
GAD antibodies result  
ICA result at diagnosis  
C-peptide if available    
Fasting  
Stimulated  
Last HbA1c (%)
Birth weight if available (Kg)
if not available, was baby (approximately)
Delivery
Acanthosis Nigricans
Any other details
Any other medical problems
Consanguinity of Parents  
Were parents related before marriage
Family history of diabetes:  
Father
Mother
Paternal grandfather
Paternal grandmother
Maternal grandfather
Maternal grandmother
Siblings
Children (if applicable)
Referring Physician’s details  
Doctor’s Name
Qualification
Specialization
Mobile No  
Clinic No  
Residence No  
E-mail address  
Address to which the report should be sent
City
State * 
Pincode
           

 

























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