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Patient {{$iPatientNo}}

(To be filled only by physician)

A retrospective cross-sectional, observational survey study to analyse role of alpha GPC & piracetam in treatment of post stroke management.

Inclusion criteria:

Patients of stroke taking alpha GPC & piracetam as treatment.

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
Hypertension
Diabetes
Coronary heart disease
Depression
Obesity
Arrhythmia
Gastrointestinal disease
Mention others if any

Name of Primary drug i.e drug started initially

Daily dose of primary drug(mg/ day)

Place in therapy *

Use of Alpha GPC & piracetam in this patient as:

1^st add-on 2^nd add-on 3^rd add-on

Total daily dose of alpha GPC & piracetam*

Alpha GPC 250 mg + piracetam 800 mg Alpha GPC 500 mg + piracetam 1600 mg Alpha GPC 1000 mg + piracetam 2400 mg Alpha GPC 1500 mg + piracetam 3200 mg

Specify, if any other(mg/day)

Reasons for choosing alpha GPC & piracetam*

Kindly tick the potential reasons for choosing in this patient

Higher choline availability

Acts faster and more completely

Exhibits neuromodulatory function

Higher improvement in cognitive dysfunction

Improvement in post stroke aphasia

Improvement in mental impairment

Better compliance

Better quality of life

Concomitant medication, if any

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

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