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Rifaximin

A Real-World Evidence Study to Evaluating the Effectiveness, Safety, and Patient-Reported Outcomes of Rifaximin for the Treatment of Diarrhea and Irritable Bowel Syndrome (IBS) at various clinics across India.

BASIC DETAILS

Date *

Patient Initials*

Eligibility of the subjects

Please tick (✔) as applicable
		Yes	No
1	Male or female subjects within the age group 18 or above
2	Subject Diagnosed with diarrhea or IBS-D
3	Prescribed Rifaximin as part of routine clinical care.
4	Available clinical records and follow-up data.

Demographic data

Gender*

Male Female

Age *

Height (cm) *

Weight (kg) *

Comorbidities *

Anxiety Depression Hyper tension Chronic kidney disease Diabetes Heart Failure Anemia Others

Diagnosis and treatment details

Primary diagnosis *

Diarrhea IBS-D

Other Relevant Diagnoses

Indication for Rifaximin *

Initial Dose & frequency: *

Duration of treatment *

Start month

End month

Baseline symptoms (Before use of Ursodeoxycholic Acid)

Diarrhea Frequency*

Number of episodes per day

Number of episodes per week

Stool Consistency (As per Bristol stool scale) *

Abdominal pain *

Mild Moderate Severe

Other Symptoms

Post treatment symptoms

Diarrhea Frequency*

Number of episodes per day

Number of episodes per week

Stool Consistency (As per Bristol stool scale) *

Abdominal pain *

Mild Moderate Severe

Other Symptoms

{{--

Follow up period *

Start date

End date

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Symptom Relief

Diarrhea Relief *

Improved No change Worsened

Abdominal Pain Relief *

Improved No change Worsened

Other Symptoms Relief *

Improved No change Worsened

Other Symptoms Relief

Overall Satisfaction with Treatment

Rating *

Very Satisfied Satisfied Neutral

Comments if any (Additional patient comments)

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