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Patient {{$iPatientNo}}

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A retrospective cross-sectional, observational survey study to analyze role of clonazepam in management of panic disorder.

Inclusion criteria

Adult patients with panic disorder & prescribed clonazepam as a treatment option

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
Depression
Anxiety
Substance use disorder
Mention others if any

Place in therapy for Clonazepam*

1^st line option 2^nd line option 3^rd line option
Specify if any other

Daily Dose of Clonazepam*

0.25mg 0.5mg 1mg 2mg
Specify if any other (mg/day)

Reasons for choosing therapy*

Concomitant medication, if any

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

Any other comments