Digicon

@if (isset(session()->get('doctor')['vCentralCode'])) {{ session()->get('doctor')['vCentralCode'] }} @endif

@if (isset(session()->get('doctor')['vCentralCode']))

Logout

@endif

@csrf

@if (isset(session()->get('doctor')['vCentralCode']))

Back

@else

@endif

Patient {{ $iPatientNo }}

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

A retrospective cross-sectional, observational survey study to analyse role of
fixed dose combination (FDC) of Desvenlafaxine and Clonazepam in depression.

Inclusion criteria:

Patients of Major depressive disorder (MDD) taking fixed dose combination (FDC) of Desvenlafaxine and Clonazepam

DEMOGRAPHIC DATA

Initials*

Serial No.*

Age (yr) *

Weight (kgs)*

Gender *

Male Female

Marital status *

Single Married

Occupation *

Student Employed Unemployed Other

Name of clinic/hospital*

Date of data collection*

DETAILS OF DIAGNOSIS AND TREATMENT

Diagnosis *

Symptoms observed *

Time since diagnosis*

Newly diagnosed Less than 3 months 3 months to Less than 6 months 6 months to Less than 1 Year More than 1 year

Comorbidities, if any*

Yes No

Comorbidities, if Yes

Conditions	YES or NO	Year	Months
Anxiety
Hypertension
Diabetes
Cardiovascular disease
Stroke
Mention others if any

Concomitant medication, if any

Sr. No	Generic Name	Route & Dose	Duration (months)
1
2
3
4
5

Any other comments

Patient {{ $iPatientNo }}

Inclusion criteria:

DEMOGRAPHIC DATA

DETAILS OF DIAGNOSIS AND TREATMENT

Mention others if any

Concomitant medication, if any

1

2

3

4

5