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Patient {{$iPatientNo}}

(To be filled only by physician)

A retrospective cross-sectional, observational survey study to analyze role of Duloxetine in diabetic peripheral neuropathic pain in adults.

Inclusion criteria:

Adult patients with diabetes and neuropathic pain & prescribed duloxetine as treatment

DEMOGRAPHIC DATA

Initials*

Serial No.*

Age (yr) *

Weight (kgs)*

Gender *

Male Female

Marital status *

Single Married

Name of clinic/hospital*

Date of data collection*

DETAILS OF DIAGNOSIS AND TREATMENT

Comorbidities, if Yes

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

Place in therapy *

Use of Duloxetine therapy in this patient as:

First- line option Inadequate response to initial therapy

Total daily dose of Duloxetine*

20mg 30mg 40mg 60mg

Dosing*

Once daily BID Others

Reasons for choosing neuropathic 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
1
2
3
4
5

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