Alkem

Date of Assessment *

Subject Initials *

OPD *

IPD *

Age (Completed years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Patients with confirmed case of peripheral neuropathy? *

Yes No

Clinical Signs and Symptoms *

Clinical Diagnosis *

Duration of current illness *

Gender of the patient diagnosed with peripheral neuropathy *

Male Female

Underlying cause of peripheral neuropathy *

Diabetic Peripheral Neuropathy Post-Herpetic Neuralgia Post-Surgical Neuropathy Spinal Cord Injury Traumatic Nerve Injury Chemotherapy-Induced Peripheral Neuropathy Idiopathic Other

History of Any Other Neurological Disorders? *

Yes No

Previous medications used for current illness (if any)

Concomitant Disease	Medication	Dose	Frequency	Indication

Methylcobalamin and pregabalin combination therapy prescribed *

Yes No

Brand Name *

Marketing Company Name *

Dose *

Frequency *

Total Duration of therapy (days) *

Other medications prescribed for T/t

Medication	Dose	Frequency	Duration

Parameter *	Before Therapy *	After Therapy *
10-point NRS score for Pain Intensity
Any Positive Neuropathic Symptoms Present? (e.g., burning, tingling, shooting pain, electric shock-like sensation, allodynia)	Yes No	Yes No
Any Negative Neuropathic Symptoms Present? (e.g., numbness, loss of sensation, reduced vibration sense, muscle weakness)	Yes No	Yes No

Clinical outcome at the end of methylcobalamin and pregabalin combination therapy *

Resolution Improvement No Change Worsening

Need of additional/rescue analgesics (if any)

Adverse events noted due to study medication *

Yes No

If yes, add details
AE. No	Adverse Event Term	Date of onset (DD/MM/YYYY)	Date of resolution (DD/MM/YYYY)	Severity	Action Taken (Specify)	Treatment given	Relationship with Study Drug	Outcome	Serious Adverse Event
1						Yes No			Yes No
2						Yes No			Yes No
3						Yes No			Yes No
4						Yes No			Yes No
Severity: 1- Mild; 2- Moderate; 3- Severe; +Action Taken: 1- No Change in IP, 2- IP Temporarily Interrupted, 3- IP Permanently Discontinued, 4- Other, specify *If 'Treatment given 'is ticked as 'Yes' then relevant information should be captured on Prior and concomitant Medication Form. † Relationship: 1= Related, 2= Not Related ++Outcome: 1 = Resolved, 2= Recovered/ Resolved with Sequelae, 3= Recovering/ Resolving, 4=Not Recovered/ Not Resolved, 5= Fatal/ result in death, 6= Unknown

Nervmax

ASSESSMENT 1 - THERAPY EVALUATION

DEMOGRAPHICS and ANTHROPOMETRY

MEDICAL AND SURGICAL HISTORY

CONCOMITANT DISEASE ANDMEDICATION

TREATMENT OF CURRENT MEDICAL ILLNESS

PAIN INTENSITY AND SEVERITY

CLINICAL RESPONSE

ADVERSE EVENTS