Alkem

Patient code (Do not write name here) *

Date *

Diagnosis : Neuropathic Pain *

Patient's Age *

Gender*

Male Female

Height (cm) *

Weight (kg) *

Presenting symptoms at the time of diagnosis *

Allodynia Paresthesia Burning sensation Shooting pain/Electric shock like Intolerance to temperature Any other

Pregabalin + Duloxetine *

50/20 mg 75/20 mg 75/30 mg

Frequency *

Once a day Twice a day

Pain intensity score: Numeric Rating Scale (0-10) *

0=No pain

10= Highest pain

NRS baseline
NRS post 3 months

Daily sleep interfering rating scale (DSIRS) *

0=No disturbance

10= highest disturbance

DSIRS baseline
DSIRS post 3 months

Physician's global assessment *

Excellent Good Average Poor

Treatment was well tolerated *

Yes No

Adverse drug reactions observed *

Yes No

BASIC DETAILS