Clinical Practice Documentation Questionnaire for Rapilif-M Combikit
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Initials:
D.O.B:
Weight (in Kg):
Height (in m):
Pulse Rate:
BP:
Obesity
*
Yes
No
Diabetes
*
Yes
No
Cardiovascular Disease (CVD):
*
Yes
No
If Yes Specify:
Hypercholestrolemia
*
Yes
No
Hypertension (HTN):
*
Yes
No
Kidney Impairment
*
Yes
No
If Yes, GFR (mL/min/1.73m2)
*
30-60
15-30
<15
Liver Impairment
*
Yes
No
If Yes,
*
Mild
Moderate
Severe
Other systemic condition(s) if any, please specify
Any Surgery:
Any Cancer:
1. What were the urinary symptoms of the patient at the time BPH with co-existing OAB was diagnosed? (One or more options might be applicable.)
A. Incomplete emptying
F. Straining
B. Increased frequency
G. Nocturia
C. Intermittency
H. Urge incontinence
D. Urgency (increased urge)
l. Hesitancy
E. Weak stream
J. Terminal dribbling
Other urinary symptom(s) if any, please specify:
2. What was the Rapilif-M combikit (henceforth referred to as 'the combikit') given as?
A. First-line therapy
C. Switch-over from other drug combinations (a-blocker plus anticholinergic)
B. Replacement to silodosin monotherapy
3. What was the reason if the combikit was prescribed as a replacement to silodosin (or any other a-blocker) monotherapy?
A. Symptoms were not relieved
C. Other reason, specify
B. An adverse event occurred
If yes, please specify:
4. If prescribed as a switch-over from other drug combination (a-blocker plus anticholinergic), please select the previously administered drug combination.
A. Silodosin + Solifenacin
C. Alfuzosin + Solifenacin
E. Others, Specify:
B. Tamsulosin+ Solifenacin
D. Tamsulosin + Tolterodine
If yes, please specify:
5. What was the reason if the combikit was prescribed as a switch-over from other drug combination?
A. Symptoms were not relieved
C. Other reason, specify:
B. An adverse event occurred
If yes, please specify:
6. How long was the combikit prescribed?
A. 0-4 weeks
C. 8-12 weeks
B. 4-8 weeks
D. > 12weeks
7. What was the daily dose prescribed?
A. Silodosin 8 mg + mirabegron 25 mg
B. Silodosin 8 mg + mirabegron 50 mg
8.What was the effect of treatment with the combikit on the patient's BPH symptoms?
A. Remarkable improvement
C. Minimal improvement
B. Moderate improvement
D. No improvement
9. What were the pre-treatment and post-treatment total IPSS scores?
A. Pre-treatment:
B. Post-treatment:
If yes, please specify:
If yes, please specify:
Which of the above do you regard as most troublesome (1-7)
Total Prostate Symptom Score
10. What was the effect of treatment with the combikit on the patient's OAB symptoms?
A. Remarkable improvement
C. Minimal improvement
B. Moderate improvement
D. No improvement
11. What were the pre-treatment and post-treatment total OABSS scores?
A. Pre-treatment:
B. Post-treatment:
If yes, please specify:
If yes, please specify:
How many times do you typically urinate from waking in the morning until sleeping at night?
≤ 7 (0)
8-14 (1)
≥ 14 (2)
Frequency (Score)
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)
Frequency (Score)
How often do you have a sudden desire to urinate, which is difficult to defer?
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)
Frequency (Score)
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)
times a day (4)
5 times a day or more (5)
Frequency (Score)
12. How was the patient's compliance with the combikit treatment?
A. Excellent
C. Average
B. Good
D. Poor
13.Were any cf the following side-effects observed secondary to treatment with the combikit?
A. Ejaculatory disorders
C. Orthostatic hypotension
B. Nasopharyngitis
D. Hypertension
Any other side-effect(s):
If yes, please specify:
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