Patient Data Collection Form

Patient Information

• Patient ID: _______________________

• Age: _____________________________

• Gender: ☐ Male ☐ Female ☐ Other

• Height: __________________________

• Weight: __________________________

• Date of Birth: ____________________

• Contact Information: _______________

Medical History

• Duration of Hypertension: ___________

• Other Medical Conditions (e.g., diabetes, kidney disease):

___________________________________________

Medication History

• Current Antihypertensive Medication(s):

o Drug Name: _______________________

o Dosage: __________________________

o Frequency: _______________________

• Previous Antihypertensive Medication(s):

o Drug Name: _______________________

o Reason for Discontinuation: __________

Adverse Events

• Have you experienced any side effects from your hypertension medication? ☐ Yes ☐ No

• If yes, please specify:

o Type of Adverse Event: ___________________________________

o Date of Onset: ________________________________________

o Duration: ____________________________________________

o Severity: ☐ Mild ☐ Moderate ☐ Severe

 o Action Taken: ☐ Medication Discontinued ☐ Dose Reduced ☐ No Action ☐ Other
(specify): ______________

o Outcome: ☐ Resolved ☐ Ongoing ☐ Improved ☐ Worsened

• Did you report this side effect to your healthcare provider? ☐ Yes ☐ No

• Additional Comments: ________________________________________

Lifestyle and Compliance

• Do you adhere to your medication regimen as prescribed? ☐ Always ☐ Sometimes ☐ Rarely

• Do you follow a specific diet or exercise routine to manage your hypertension? ☐ Yes ☐ No

• If yes, please specify: ______________________________________

Informed Consent

• I consent to the use of my medical data for this research study: ☐ Yes ☐ No

• Signature: __________________________

• Date: _______________________________

Prescriber Data Collection Form

Prescriber Information

• Prescriber ID: _______________________

• Name: _____________________________

• Specialization: ______________________

• Contact Information: _______________

Patient Information

• Patient ID: _______________________

• Age: _____________________________

• Gender: ☐ Male ☐ Female ☐ Other

• Height: __________________________

• Weight: __________________________

• Date of Birth: ____________________

Clinical Management of Hypertension

• Duration of Hypertension Treatment for this Patient: ___________

 • Current Antihypertensive Medication(s) Prescribed:

o Drug Name: _______________________

o Dosage: __________________________

o Frequency: _______________________

• Previous Antihypertensive Medication(s) Prescribed:

o Drug Name: _______________________

o Reason for Change/Discontinuation: __________

Adverse Events Reporting

• Have any adverse events been reported by this patient? ☐ Yes ☐ No

• If yes, please specify:

o Type of Adverse Event: ___________________________________

o Date of Onset: ________________________________________

o Duration: ____________________________________________

o Severity: ☐ Mild ☐ Moderate ☐ Severe

o Action Taken: ☐ Medication Discontinued ☐ Dose Reduced ☐ No Action ☐ Other

(specify): ______________

o Outcome: ☐ Resolved ☐ Ongoing ☐ Improved ☐ Worsened

• Did you report this side effect to the pharmacovigilance system? ☐ Yes ☐ No

Clinical Judgment and Treatment Plan

• Based on the adverse events, did you alter the patient's treatment plan? ☐ Yes ☐ No

• If yes, please specify the changes made: ______________________________________

• Do you regularly monitor your patients for adverse events related to hypertension treatment?
☐ Yes ☐ No

• Additional Comments: ________________________________________

Informed Consent

• I consent to the use of my professional data for this research study: ☐ Yes ☐ No

• Signature: __________________________

• Date: _______________________________
Form No. 02

Patient Data Collection Form

Section A: Patient Information

• Patient ID: ___________________________

• Age: _________________________________

• Gender: ☐ Male ☐ Female ☐ Other

• Height: ______________________________

• Weight: ______________________________

• Date of Birth: _________________________

• Contact Information: ___________________

Section B: Medical History

• Duration of Hypertension (years): ____________________

• Comorbid Conditions (e.g., diabetes, kidney disease, etc.):

______________________________________________________

• Family History of Hypertension: ☐ Yes ☐ No

Section C: Medication History

• Current Antihypertensive Medication(s):

o Drug Name: _________________________

o Dosage: ____________________________

o Frequency: __________________________

o Start Date: __________________________

• Previous Antihypertensive Medication(s):

o Drug Name: _________________________

o Reason for Discontinuation: ___________

Section D: Adverse Events

• Have you experienced any side effects from your hypertension medication? ☐ Yes ☐ No

• If yes, please provide details:

 o Type of Adverse Event: ___________________________________

o Date of Onset: __________________________________________

o Duration: ______________________________________________

o Severity: ☐ Mild ☐ Moderate ☐ Severe

o Action Taken: ☐ Medication Discontinued ☐ Dose Reduced ☐ No Action ☐ Other

(specify): ___________________

o Outcome: ☐ Resolved ☐ Ongoing ☐ Improved ☐ Worsened

• Did you report this side effect to your healthcare provider? ☐ Yes ☐ No

Section E: Lifestyle and Compliance

• Do you adhere to your medication regimen as prescribed? ☐ Always ☐ Sometimes ☐ Rarely

• Do you follow any specific lifestyle changes to manage hypertension? ☐ Yes ☐ No

• If yes, please specify:

_______________________________________________________________________

Section F: Consent

• I consent to the use of my medical data for this research study: ☐ Yes ☐ No

• Signature: ___________________________

• Date: _______________________________

Prescriber Data Collection Form

Section A: Prescriber Information

• Prescriber ID: ___________________________

• Name: _________________________________

• Specialization: __________________________

• Contact Information: _____________________

Section B: Patient Information

• Patient ID: _____________________________

• Age: __________________________________

• Gender: ☐ Male ☐ Female ☐ Other

Section C: Clinical Management

 • Duration of Hypertension Treatment for this Patient (years): ______________

• Current Antihypertensive Medication(s):

o Drug Name: __________________________

o Dosage: _____________________________

o Frequency: ___________________________

• Previous Antihypertensive Medication(s):

o Drug Name: __________________________

o Reason for Change/Discontinuation: ______

Section D: Adverse Events Reporting

• Have any adverse events been reported by this patient? ☐ Yes ☐ No

• If yes, please provide details:

o Type of Adverse Event: ___________________________________

o Date of Onset: __________________________________________

o Duration: ______________________________________________

o Severity: ☐ Mild ☐ Moderate ☐ Severe

o Action Taken: ☐ Medication Discontinued ☐ Dose Reduced ☐ No Action ☐ Other

(specify): ___________________

o Outcome: ☐ Resolved ☐ Ongoing ☐ Improved ☐ Worsened

• Did you report this side effect to the pharmacovigilance system? ☐ Yes ☐ No

Section E: Treatment Plan

• Based on the adverse events, did you alter the patient's treatment plan? ☐ Yes ☐ No

• If yes, please specify the changes made:

_________________________________________________

• Do you regularly monitor your patients for adverse events related to hypertension treatment?
☐ Yes ☐ No

Section F: Consent

• I consent to the use of my professional data for this research study: ☐ Yes ☐ No

• Signature: ___________________________

• Date: _______________________________