Digicon

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Patient {{ $iPatientNo }}

(Kindly fill in the relevant information or tick, as appropriate.)

DEMOGRAPHIC DATA

Age (in Years) *

Gender *

Male Female

GENERAL EXAMINATION FINDINGS

Weight (in Kg) *

Heart Rate (beats/min) *

BP (mm Hg) *

DETAILS OF DIAGNOSIS

COPD severity at diagnosis*

GOLD 1 GOLD 2 GOLD 3 GOLD 4

Comorbidities if any

Conditions³

YES or NO

Condition since how long

Years

Months

Hypertension*

Yes No

Diabetes mellitus*

Yes No

Metabolic syndrome*

Yes No

Dyslipidemia*

Yes No

Anemia⁴*

Yes No

Asthma*

Yes No

Chronic ischemic heart disease*

Yes No

Sleep disorders*

Yes No

Chronic Kidney Disease*

Yes No

Mention others if any

	Yes No
	Yes No

Current COPD medications/Treatment regimen (Kindly tick the ongoing medications in this patient)*
COPD medications before baseline treatment	Tick multiple if applicable	If yes, which molecule?
COPD medications before baseline treatment	Tick multiple if applicable
No treatment
ICS
LABA
SABA
Phosphodiesterase inhibitors
Acetyl cysteine

Appropriate reasons for prescribing the Acebrophylline + N- Acetylcysteine fixed dose combination (Kindly tick the appropriate reasons for in this patient)*
Attributes	Tick all the applicable appropriate attributes/ reasons for prescribing the above Acebrophylline + N- Acetylcysteine fixed dose combination in this patient

Efficacy in terms of symptom control
Efficacy in terms of improvement of FEV1
Efficacy in terms of exacerbation reduction
Tolerability
Faster onset of action
Presence of Co-morbidities

Follow-up for these patients*

At 1 months At <3 months 3-6 months 7-12 months

Other Class of Drug given along with above therapy*

Class of Drug

Generic Name

Dose

Duration

Short-Acting Beta-Agonists (SABAs)

Short-acting muscarinic antagonists (SAMA)

Leukotriene receptor antagonists (LTRA)

Theophylline or acebrophylline

Mention others if any