DigiCon

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(Please fill complete detail in patient data capture form for each patients & SAVE to prevent data loss)

Name*

ID No.*

Initials*

Serial No.*

Gender*

Male Female

Age(yr)*

Wt(kg)*

Diagnosis*

Co-existing diagnosis, if any

Concomitant medication*

Dose	Date	Dose & Frequency of Faropenem tablet	Likert scale (Ask the patient have the symptoms improved?
Dose	Date	Dose & Frequency of Faropenem tablet	Strongly agree	Agree	Undecided	Disagree	Strongly disagree
Day 1
Day 5 or End of treatment

Incase dose has not been administered, or interrupted please specify reason for same

Physician Assessment at the end of Observation period (please the option):

Was Faronem effective

Yes No Don't Know

		1.
Adverse Events		1.
		2.
		3.
Start Date
Pattern	Isolated: 1 Intermittent: 2 Continuous: 3
Severity	Isolated: 1 Intermittent: 2 Continuous: 3
SAE^$	Yes: 1 No: 2
Causality *
Action (Counter active medication)	Yes: 1 No: 2
Action (Study active medication)	None: 1 Dose Reduced: 2 Discounted: 3
SAE^$	Yes: 1 No: 2
Outcome^#
Stop Date: