DigiCon

Patient initials *

Patient No *

Date *

Age(in Years) *

Gender *

Male Female

Weight(in Kg)

Height(in cm)

Blood pressure (BP)

Pulse (per minute)

Symptoms & Sign *

International prostate symptom score :

	Less than 1 time in 5	Less than half the time	About half the time	More than half the time	Almost always
Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating?	1	2	3	4	5
Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating?	1	2	3	4	5
Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated?	1	2	3	4	5
Urgency Over the last month, how difficult have you found it to postpone urination?	1	2	3	4	5
Weak stream Over the past month, how often have you had a weak urinary stream?	1	2	3	4	5
Straining Over the past month, how often have you had to push of strain to begin urination?	1	2	3	4	5

	None	1 time	2 times	3 times	4 times	5 times or more	Your score
Nocturia Over the past month, How many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?	0	1	2	3	4	5
Total scores

Total score : 0-7 Mildly symptomatic; 8-19 moderately symptomatic: 20-35 severely symptomatic

Quality of life due to urinary symptoms	Delighted	Pleased	Mostly satisfied	Mixed Equally satisfied / dissatisfied	Mostly dissatisfied	Unhappy	Terrible
If you were to spend the rest of your life with your urinary condition the way it is now, how would you feel about that?	0	1	2	3	4	5	6

Overactive Bladder symptom score *

Question	Frequency	Score
How many times do you typically urinate from waking in the morning until sleeping (≤7=0, 8-14=1, ≥15=2)	≤7 8-14 ≥15
How many times do you typically wake up to urinate from sleeping at night until waking in the morning? (0=0, 1=1, 2=2, ≥3=3)	0 1 2 ≥3
How often do you have a sudden desire to urinate, which is difficult to deter? (Not at all=0, Less than once a week=1, Once a week or more=2, About once a day=3, 2-4 times a day=4, 5 times a day or more=5)	Not at all Less than once a week Once a week or more About once a day 2-4 times a day 5 times a day or more
How often do you leak urine because you cannot defer the sudden desire to urinate? (Not at all=0, Less than once a week=1, Once a week or more=2, About once a day=3, 2-4 times a day=4, 5 times a day or more=5)	Not at all Less than once a week Once a week or more About once a day 2-4 times a day 5 times a day or more

*Patients were instructed to circle the score that best applied to their urinary condition during the past week, the overall score was the sum of the four scores; severity - minor (total score ≤ 5) and serious (total score > 5)

Any co-morbid conditions

Condition	Please tick if present; Mention duration	Mention name of medicines
Hypertension
IHD
Heart failure
Other CVD disease
Type 2 DM
Any Other Please Specify

IHD: Ischaemic heart disease; CVD: Cardiovascular diseases; DM: Diabetes Mellitus

Diagnosis *

Sr. No	Condition	Duration
1	BPH with OAB *	Newly Diagnosed On treatment
2	Other urological conditions if present (Please mention)

BPH with OAB *: Benign prostatic hyperplasia with Over active bladder

If on treatment, please tick the appropriate details of the treatment

Name of drug	Dose / day	Duration
Silodosin	8 mg
Tamsulosin	0.4mg
Alfuzosin modified release	10 mg
Other Please mention

Investigations (if done)	Details
Qmax (If done)	ml/sec
PVR (If done)	ml
Prostate size (If done)	ml or gm

Treatment prescribed in current visit for BPH and Overactive Bladder *

Sr. No	Name of Drug	Frequency	Duration
1	SILODAL – M (Silodosin 8 mg + Mirabegron 25 mg)
2	SILODAL – M (Silodosin 8 mg + Mirabegron 50 mg)
3	Any Other Please Specify
4	Any Other Please Specify

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Understanding In-practice usage of SILODAL-M (Silodosin 8 mg capsule + Mirabegron 25/50 mg extended release tablet) in BPH with OAB patients.