Alkem

A multicenter, retrospective, real world evidence study to assess the drug utilization in Asthma patients in Indian Pulmonology Practice.

Subject ID *

Subject Initials *

Investigator *

Centre *

ASSESSMENT OF THERAPY PRESCRIBED

Date of Assessment *

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 *

Patients with confirmed case with Asthma Disease *

Yes No

Clinical Signs and Symptoms *

Chief complaints *

Duration of current illness *

Severity of disease *

Medications being used for Current Medical Condition *

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Start Date (DD-MM-YYYY)	End Date (DD-MM-YYYY)	Medication	Class	Dose	Frequency	Duration	Indication

Frequency of visits *

Any Specific Changes in treatment regimen (if available)

@for ($i = 1; $i <= 4; $i++) @for ($j = 1; $j <= 5; $j++) @endfor @endfor

Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

@for ($i = 1; $i <= 18; $i++) @endfor

Date of Assessment	Tests	Results
	@if ($i == 1) Hb (gm/dL) @endif @if ($i == 2) RBC (millions/cumm) @endif @if ($i == 3) WBC (cumm) @endif @if ($i == 4) Platelets (cumm) @endif @if ($i == 5) CRP (mg/L) @endif @if ($i == 6) FVC (L) @endif @if ($i == 7) FEV1 (L) @endif @if ($i == 8) PEF (L/min) @endif @if ($i == 9) FEF25-75% (L/sec) @endif @if ($i == 10) Bilirubin (T/D/I) (mg/dL) @endif @if ($i == 11) SGPT (U/L) @endif @if ($i == 12) SGOT (U/L) @endif @if ($i == 13) ALP (U/L) @endif @if ($i == 14) Protein (T/A/G) (g/dL) @endif @if ($i == 15) S. Cr (mg/dL) @endif @if ($i == 16) BUN (mg/dL) @endif @if ($i == 17) eGFR (mL/min/1.73m²) @endif @if ($i == 18) Specify others (if available) @endif

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