Alkem

Subject Initials *

Investigator *

Centre *

Date of Assessment *

Age (in Years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Geographical location *

Allergy *

Yes No

History of current illness *

Chief complaints *

Clinical Diagnosis *

Duration of current illness *

Medications being prescribed for Current Dental Infection *

Antibiotic sensitivity done *

Yes No

Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

Adverse events noted due to study medication *

Yes No

ADVERSE EVENT(S)
AE. No	Adverse Event Term	Date of onset (DD/MM/YYYY)	Severity	Action Taken	Treatment given	Relationship with Study Drug	Outcome	Serious Adverse Event
1					Yes No			Yes No
2					Yes No			Yes No
3					Yes No			Yes No
4					Yes No			Yes No
Severity: 1- Mild; 2- Moderate; 3- Severe; +Action Taken: 1- No Change in IP, 2- IP Temporarily Interrupted, 3- IP Permanently Discontinued, 4- Other, specify *If Treatment given is ticked as 'Yes' then relevant information should be captured on Prior and concomitant Medication Form. Relationship: 1= Related, 2= Not Related ++Outcome: 1 = Resolved, 2= Recovered/ Resolved with Sequelae, 3= Recovering/ Resolving, 4=Not Recovered/ Not Resolved, 5= Fatal/ result in death, 6= Unknown

ASSESSMENT OF THERAPY PRESCRIBED