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Patient {{$iPatientNo}}

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

A multicentre, retrospective, observational, cross-sectional, survey study to analyse
the role of Fluticasone Furoate and Vilanterol Powder for Inhalation in Asthma.

Inclusion criteria:

• Adult patients diagnosed with asthma
• Prescribed Fluticasone Furoate and Vilanterol Powder for Inhalation as part of routine practice

DEMOGRAPHIC DATA

Age (yr) *

Weight (kgs)*

Gender *

Male Female

Marital status *

Single Married

DETAILS OF DIAGNOSIS AND TREATMENT

Comorbidities, if Yes

Conditions	YES or NO	Year	Months
Chronic Obstructive Pulmonary Disease
Cardiovascular disease
Allergic conditions
Mention others if any

Place in therapy *

Use of Fluticasone Furoate and Vilanterol Powder for Inhalation in this patient as:

First-line therapy Add-on therapy

Total daily dose of Fluticasone Furoate and Vilanterol Powder for Inhalation *

100 mg/25 mcg 200 mg/25 mcg

Reasons for choosing Fluticasone Furoate and Vilanterol Powder for Inhalation *

Kindly tick the potential reasons for choosing in this patient

Efficacy in improvement of asthma symptoms

Decrease in exacerbation rates

Decrease in need of Short-Acting Beta-Agonists (SABAs)

Favorable safety profile

Presence of Co-morbidities

Once a day dosing

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