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DUE Antibiotic Protocol

A multicenter, retrospective, real world evidence study to assess the utilization and prescribing patterns of antibiotic among out-patients in India using WHO prescribing indicators and AWaRe Assessment Tool.

Subject ID *

Subject Initials *

Investigator *

Centre *

ASSESSMENT OF THERAPY PRESCRIBED

Date of Assessment *

DEMOGRAPHICS and ANTHROPOMETRY

Subject Initials *

Age (in Years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Geographical location *

Allergy *

Yes No

Smoking history *

Yes No

Occupation *

Family history *

MEDICAL AND SURGICAL HISTORY

Patients prescribed with antibiotics *

Yes No

Chief complaints *

Clinical Diagnosis *

Duration of current illness *

Severity of disease *

Previous Antibiotic used (if any)

TREATMENT OF CURRENT MEDICAL ILLNESS

Medications being used for Current Medical Condition

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Generic Name	Brand Name	Class	Dose	Frequency	Route	Duration	Indication	Empiric OR Definitive

Microbial culture sensitivity report (if available)

CONCOMITANT DISEASE and MEDICATION

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Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

ADVERSE EVENTS

Adverse events noted due to study medication *

Yes No

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ADVERSE EVENT(S)
AE. No	Adverse Event Term	Date of onset (DD/MM/YYYY)	Severity	Action Taken	Treatment given	Relationship with Study Drug	Outcome	Serious Adverse Event
{{ $j++ }}					Yes No			Yes No

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