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 }}

A multicentre, retrospective, observational survey study to analyse the role of combination of pregabalin 75 mg + nortriptyline in adult patients with neuropathic pain

Inclusion criteria:

Adult patients with neuropathic pain & prescribed combination of pregabalin + nortriptyline as treatment

DEMOGRAPHIC DATA

Initials*

Serial No.*

Age (yr) *

Gender *

Male Female

Weight (kgs)*

Marital status *

Single Married

Name of clinic/hospital*

Date of data collection*

DETAILS OF DIAGNOSIS AND TREATMENT

Comorbidities, if any

Yes No

Comorbidities, if Yes

Conditions	YES or NO	Year	Months
Peripheral arterial disease
Cardiovascular disease
Retinopathy
Mention others if any

Place in therapy *

Use of combination therapy in this patient as:

First-line option Inadequate response to initial therapy

In case of 2nd line option *

Name of Primary drug i.e drug started on initial diagnosis

Daily dose of Primary drug (mg/day)*

Dosing of pregabalin 75 mg + nortriptyline*

Once daily Others

Reasons for choosing Combination therapy*

Kindly tick the potential reasons for choosing in this patient

Decrease in frequency of pain

Decrease in severity of pain

Higher response rate

Higher symptom remission

Favorable safety profile

Presence of Co-morbidities

Patient acceptance

Better compliance

Better quality of life

Concomitant medication, if any

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

Any other comments