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.)

To evaluate the efficacy on allergic rhinitis of a combination therapy of Montelukast and levocetirizine in patients with asthma and allergic rhinitis.

Basic demography data

Age (Years)*

Height (In cms)*

Weight (In kgs )*

Body mass index (BMI)*

Occupation *

Gender *

Male Female

Smoking Status *

Non-smoker Current Smoker Past Smoker (> 3 years)

Family H/O Allergy *

Present Absent

Family H/O Asthma*

Present Absent

Diagnosis*

Type of allergic rhinitis*

Intermittent Persistent

History of past medication for same diagnosis:

Medicine *	Dose*	Frequency of dosing*	Duration (weeks)*




Any other

Details of comorbid condition*

Please mention details of additional investigation if done

	Baseline visit (%)	At 4 weeks (%)	At 8 weeks (%)
FEV1
Any Other

Please rate the response in following parameters after use of Montelukast and Levocetirizine combination

Current Treatment for Asthma:	ICS LABA SABA Oral CS Leukotriene receptor antagonists LAMA Methylxanthines Antibiotics Anti-immunoglobulin E (Omalizumab) Any Other please specify
Severity of asthma (Depending on treatment)	Mild Moderate Severe

Nasal congestion*	None	Mild (symptoms clearly present but easily tolerated)	Moderate (symptoms bothersome but tolerable)	Severe (symptoms difficult to tolerate and interferes with activity)
Baseline visit	0	1	2	3
At 4 weeks	0	1	2	3
At 8 weeks	0	1	2	3
Runny nose*	None	Mild (symptoms clearly present but easily tolerated)	Moderate (symptoms bothersome but tolerable)	Severe (symptoms difficult to tolerate and interferes with activity)
Baseline visit	0	1	2	3
At 4 weeks	0	1	2	3
At 8 weeks	0	1	2	3
Nasal / ocular itching*	None	Mild (symptoms clearly present but easily tolerated)	Moderate (symptoms bothersome but tolerable)	Severe (symptoms difficult to tolerate and interferes with activity)
Baseline visit	0	1	2	3
At 4 weeks	0	1	2	3
At 8 weeks	0	1	2	3
Sneezing*	None	Mild (symptoms clearly present but easily tolerated)	Moderate (symptoms bothersome but tolerable)	Severe (symptoms difficult to tolerate and interferes with activity)
Baseline visit	0	1	2	3
At 4 weeks	0	1	2	3
At 8 weeks	0	1	2	3
Difficult to sleep*	None	Mild (symptoms clearly present but easily tolerated)	Moderate (symptoms bothersome but tolerable)	Severe (symptoms difficult to tolerate and interferes with activity)
Baseline visit	0	1	2	3
At 4 weeks	0	1	2	3
At 8 weeks	0	1	2	3

Patient {{ $iPatientNo }}

Basic demography data

Diagnosis*

History of past medication for same diagnosis:

Any other

Details of comorbid condition*

Current Treatment for Asthma:

Severity of asthma (Depending on treatment)

Baseline visit (%)

At 4 weeks (%)

At 8 weeks (%)

FEV1

Any Other

Nasal congestion*

None

Mild (symptoms clearly present but easily tolerated)

Moderate (symptoms bothersome but tolerable)

Severe (symptoms difficult to tolerate and interferes with activity)

Baseline visit

At 4 weeks

At 8 weeks

Runny nose*

None

Mild (symptoms clearly present but easily tolerated)

Moderate (symptoms bothersome but tolerable)

Severe (symptoms difficult to tolerate and interferes with activity)

Baseline visit

At 4 weeks

At 8 weeks

Nasal / ocular itching*

None

Mild (symptoms clearly present but easily tolerated)

Moderate (symptoms bothersome but tolerable)

Severe (symptoms difficult to tolerate and interferes with activity)

Baseline visit

At 4 weeks

At 8 weeks

Sneezing*

None

Mild (symptoms clearly present but easily tolerated)

Moderate (symptoms bothersome but tolerable)

Severe (symptoms difficult to tolerate and interferes with activity)

Baseline visit

At 4 weeks

At 8 weeks

Difficult to sleep*

None

Mild (symptoms clearly present but easily tolerated)

Moderate (symptoms bothersome but tolerable)

Severe (symptoms difficult to tolerate and interferes with activity)

Baseline visit

At 4 weeks

At 8 weeks