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Patient {{$iPatientNo}}

(To be filled only by physician)

A retrospective cross-sectional, observational survey study to analyze role of flexible dosing of
Gabapentin + Nortriptyline FDC in patients with neuropathic pain not responding to monotherapy

Inclusion criteria:

Adult patients with neuropathic pain not responding to monotherapy & prescribed gabapentin +nortriptyline 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 combination therapy in this patient due to inadequate response to initial therapy as:

Switch over from the initial therapy Adjuvant to the initial therapy

Total daily dose of FDC *

400mg/10mg 200mg/10mg 100mg/10mg Other

Dosing*

Once daily Twice 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