Alkem

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Case Record Form (CRF)

BASIC DETAILS

Patient code (Do not write name here) *

Date *

Patient's Age (years) *

Gender *

Male Female

Weight (in Kg) *

Height (in cm) *

Previous Diagnosis of OAB *

Yes No

Family History of OAB *

Yes No

Other Urological Conditions *

Yes No

	If present, mention severity as per OABSS score
Urgency	0 1 2 3 4 5
Urgency Incontinence	0 1 2 3 4 5
Incontinence	0 1 2 3 4 5
Frequency	0 1 2 3 4 5
Walking to urinate	0 1 2 3 4 5
Total OABSS Score (baseline)
Total OBSS Score (4week post treatment)
Total OBSS Score (8week post treatment)
Total OBSS Score (12week post treatment)

Uroflowmetry

Pharmacotherapy *

Drug class	Drug	Dose	Frequency
Anticholinerg ics	Darifenacin Oxybutynin Solifenacin	5 mg 7.5 mg 10 mg 15 mg	Once a day Twice a day
Beta 3 agonists	Mirabegron	25 mg 50 mg	Once a day Twice a day
Botulinum
Alpha reductase inhibitors	Finasteride Dutasteride	0.5 mg 1 mg 5 mg 10 mg	Once a day Twice a day
Alpha blockers	Tamsulosin Silodosin	0.4 mg 0.8 mg 4 mg 8 mg	Once a day Twice a day
Other

Behavioral Therapy Recommended *

Fluid Intake Dietary changes Reduce Alcohol Consumption Kegel's exercise OAB diary

ADRs observed *

Yes No

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