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Patient {{$iPatientNo}}

(To be filled only by physician)

A retrospective, cross-sectional observational survey study to analyse the role of Vortioxetine in patients with depression having cognitive deficits.

Inclusion criteria:

Adult patients diagnosed with depression having cognitive deficits & prescribed Vortioxetine as monotherapy or adjuvant therapy.

DEMOGRAPHIC DATA

Initials*

Serial No.*

Age (yr) *

Weight (kgs)*

Gender *

Male Female

Marital status *

Single Married

Name of clinic/hospital*

Date of data collection*

DETAILS OF DIAGNOSIS AND TREATMENT

Comorbidities, if Yes

Conditions	YES or NO	Year	Months
Anxiety
Substance use disorder
Sleep disorders
Mention others if any

Place in therapy *

Use of Vortioxetine in this patient as:

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

Dose of Vortioxetine*

5mg 10mg 20mg

Reasons for choosing Vortioxetine*

Concomitant medication, if any

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

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