Interaction Suspect Tick if Start Date End Date Medication Dose Frequency Route Indications with study Drug ongoing (DD/MM/YYYY) (DD/MM/YYYY) drug (tick) (tick) Relevant Tests List only relevant confirmatory test results for event(s), for example from blood tests, diagnostic imaging Normal Normal Date Test Result Comments Range- Low (DD/MM/YYYY) Rechallenge Information
Medication Start Date (DD/MM/YYYY) End Date (DD/MM/YYYY) Tick if ongoing Dose Frequency Route Indications Suspect Drug (tick) Interaction with study drug (tick) Relevant Tests List only relevant confirmatory test results for event(s), for example from blood tests, diagnostic imaging Test Date (DD/MM/YYYY) Result Normal Range- Low Normal Comments Rechallenge Information