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(Kindly fill in the relevant information or tick, as appropriate.)

Surveillance for In-Practice Usage and Prescription Pattern of SUSTEN SR Tablets

Doctor Name: *

ID No.:

Patient Initials*

Age (years) *

Weight (kgs)*

Date of Visit*

Diagnosis *

Threatened Abortion Recurrent pregnancy loss

Concomitant conditions (if any)

Parameter Name
Present Complaint* (Select all applicable)	Spotting/Bleeding stopped Abdominal cramping Pelvic pain, pelvic pressure and/or back pain Other Please specify
Gestational Age* (Select only one option)	<7 weeks 7-8 weeks 9-10 weeks >10 weeks
Fetal Heart Rate (Beats per Minute) (If available)
Past Obstetric History
Previous Pregnancy*	Yes No
Complications with Previous Pregnancy*	Yes No Not Applicable
1. Mother*
2. Baby*

*Physician assessment on outcome(Tick all applicable)**	Spotting/Bleeding stopped Pregnancy continued >20 weeks Miscarriage Not Prevented
Fetal Heart Rate (Beats per Minute) (If available)
Physician assessment on tolerability *	Excellent Very good Good Satisfactory Poor
Physician assessment on route & dosage convenience *	Excellent Very good Good Satisfactory Poor