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 of Doctor*

@else

Name of Doctor *

@endif

Patient’s Details

Initials *

Age(in Years) *

Weight(in Kg) *

Gender *

Male Female

Diagnosis

Treatment Details

Drug Name	Dose	Frequency
Drug Name	Dose	BID	TID
ROLES 20 mg Tablets
ROLES-D Capsules^$
ROLES BD Capsules#
Concomitant drug, If any

(*Rabeprazole 20 mg; $: Rabeprazole 20 mg enteric coated + Domperidone 10mg immediate release and 20 mg sustained-release; #: Rabeprazole 20 mg enteric coated + Levosulpiride 75 mg sustained-release)

CLINICAL EFFICACY ASSESSMENT

Heartburn, epigastric pain and nausea

	Heartburn	Epigastric pain	Nausea
Week 1 (Day 0)
Week 4 (Day 28±2)

Key:0= None, 1= Mild, 2= Moderate, 3= Severe

Dysphagia, chest pain and dry cough

	Dysphagia	Chest pain	Dry cough
Week 1 (Day 0)
Week 4 (Day 28±2)

Regurgitation and bloating

	Regurgitation	Bloating
Week 1 (Day 0)
Week 4 (Day 28±2)

Overall degree of relief?

	Relief
Week 1 (Day 0)
Week 4 (Day 28±2)

Degree of relief scale:
1=completely relieved, 2=considerably relieved, 3=somewhat relieved, 4=unchanged, 5=somewhat worse, 6=considerably worse, 7=became more worst

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Patient {{$iPatientNo}}

Doctor’s Details

Patient’s Details

Diagnosis

Treatment Details

Concomitant drug, If any

CLINICAL EFFICACY ASSESSMENT

Adverse Event