Alkem

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Activlife

A multicenter, retrospective, real world evidence study to evaluate the utilization and effectiveness of multivitamin and multimineral supplementation in adult and pediatric patients.

ASSESSMENT 1 - START OF THERAPY

Date of Assessment *

DEMOGRAPHICS and ANTHROPOMETRY

Age (Completed years) *

Gender *

Male Female

Height (in cm) *

Weight (kg) *

MEDICAL AND SURGICAL HISTORY

Signs and Symptoms *

Clinical Diagnosis (if any)

Concomitant medication for current medical illness (If Any)

CONCOMITANT DISEASE and MEDICATION

Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

LABORATORY PARAMETERS

Complete laboratory details on second last page.

SUPPLEMENTATION DETAILS

Reason for MVM Supplementation (Tick () all that apply) *

Acute infection (bacterial/viral) Nutritional deficiency - probable micronutrient Recovering from acute infection/illness (convalescence) Chronic illness

Other

Formulation *

Tablet Capsule Syrup

Brand Name of Supplement *

Dose *

Frequency *

Duration of Therapy (in days) *

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ASSESSMENT 2 - END OF END OF MVM SUPPLEMENTATION

Date of Assessment *

CLINICAL SYMPTOMS

Symptoms *	Assessment-1 *	Assessment-2 *
Fatigue	Present Absent Not Assessed	Present Absent Not Assessed
Appetite Loss	Present Absent Not Assessed	Present Absent Not Assessed
Pallor	Present Absent Not Assessed	Present Absent Not Assessed
Icterus	Present Absent Not Assessed	Present Absent Not Assessed
Specify others (if available)

OVERALL CLINICAL OUTCOME

Reported by HCP *

Improved No Change Worsened

Reported by Patient *

Excellent - Complete resolution of symptoms and significant improvement in overall well-being Good - Noticeable improvement in most symptoms and overall condition Fair - Mild improvement; some symptoms persist Poor - No improvement or worsening of symptoms

LABORATORY PARAMETERS (if available)

Reports	Assessment-1	Assessment-2
Hb	gm/dL	gm/dL
CRP	mg/dL	mg/dL
WBC	µL	µL
Other (Specify)

Adverse events noted due to study medication *

Yes No

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