Alkem

Date of Assessment *

Subject Initials *

OPD *

IPD *

Age (Completed years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Patients with confirmed case *

Postoperative pain Soft tissue injury Others

Clinical Signs and Symptoms *

Clinical Diagnosis *

Duration of current illness *

History of chronic pain condition prior to surgery or injury *

Yes No

Type of surgery or injury (if any)

Orthopedic Dental General ENT Other

Tissue types involved (if applicable, select all that apply) *

Skin Subcutaneous tissue Muscle Tendon Ligament Fascia Nerve Other

Previous analgesics or anti-inflammatory agents used (if any)

10-point NRS score for Pain Intensity *
Before Therapy
After Therapy

Diclofenac, paracetamol, and serratiopeptidase combination therapy prescribed *

Yes No

Brand Name *

Marketing Company Name *

Dose *

Frequency *

Total Duration of therapy (days) *

Other medications prescribed for T/t

Clinical outcome at the end of diclofenac, paracetamol, and serratiopeptidase combination therapy *

Resolution Improvement No Change Worsening

Need of additional 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

ASSESSMENT 1 - THERAPY EVALUATION