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Patient {{$iPatientNo}}

(To be filled only by physician)

A multicentre, retrospective, observational survey study to analyse the role of fixed dose combination (FDC)
drug of paroxetine and clonazepam in elderly patients with co-morbid depression and anxiety

Inclusion criteria:

Elderly patients (60 years and above) suffering from co-morbid depression and anxiety & prescribed FDC as first line or add on to other antidepressants

DEMOGRAPHIC DATA

Initials*

Serial No.*

Age (yr) *

Weight (kgs)*

Name of clinic/hospital*

Date of data collection*

Gender *

Male Female

Marital status *

Single Married

DETAILS OF DIAGNOSIS AND TREATMENT

Comorbidities, if Yes

Conditions	YES or NO	Year	Months
Insomnia
Eating disorder
Substance use disorder
Mention others if any

Place in therapy *

Use of FDC in this patient as:

First- line option 1^st add-on 2^nd add-on 3^rd add-on

Total daily dose of the FDC*

12.5mg+0.25mg 12.5mg+0.5mg 25mg+0.5mg

Reasons for choosing FDC (paroxetine + clonazepam)*

Concomitant medication, if any

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

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