Alkem

Subject Initials *

Investigator *

Centre *

Was patient in OPD/IPD ? *

OPD IPD

Age (in Years) *

Gender *

Male Female

Height (in cm) *

Weight (in Kg) *

Pediatric patients with confirmed case of MOLD *

Yes No

Presenting Signs and Symptoms *

Clinical Signs and Symptoms *

Clinical Diagnosis *

Duration of current illness *

Previous medicines used (if any)

CONCOMITANT DISEASE and MEDICATION

Concomitant Disease	Duration of Disease	Medication	Dose	Frequency

Nebulized hypertonic saline prescribed*

Yes No

Brand Name *

Marketing Company Name *

Dose *

Frequency *

Duration *

Other medications prescribed for T/t

Medication	Dose	Frequency	Duration

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

DEMOGRAPHICS and ANTHROPOMETRY