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.)

Doctor’s Details

@if(isset(session()->get('doctor')['vCentralCode']))

Name *

@else

Name *

@endif

ID No. *

Patient’s Details

Initials *

Serial No.*

Sex *

Age(in Years) *

Wt (kg)*

Diagnosis*

Co-existing diagnosis, if any

Treatment

Montek FX

Drug	Start Date	Dose	Stop Date

Concomitant drugs, if any

CLINICAL EFFICACY ASSESSMENT

1. Nasal symptoms score

Severity of Nasal Symptom *	Patients Response
Rhinorrhea
Congestion
Sneezing
Itching
Total score

Score Symptoms: 0=None No symptoms evident; 1=Mild Symptom present but easily tolerated; 2=Moderate Definite awareness of symptom; bothersome but tolerable; 3=Severe Symptom hard to tolerate; interferes with daily activity

CLINICAL ASSESSMENT OF SEDATIVE EFFECTS

1. Did you have sleepiness after taking this drug?

Yes No

2. What was the degree of the sleepiness?

Hard to stay awake

{{$ActivityTypeName}}

Patient {{$iPatientNo}}

Doctor’s Details

Patient’s Details

Treatment

CLINICAL EFFICACY ASSESSMENT

CLINICAL ASSESSMENT OF SEDATIVE EFFECTS

CLINICAL SAFETY ASSESSMENT

Adverse Events