Adverse Events Assessment Form Participant No.:_________ Evaluator:__________ Date:____________
| Adverse events | Time of occurrence | End time | Outcomes | Results of causal relationship analysis | Quitting research |
| □Self-remission □Remission after treatment □Not remitted □Unclear | □Definitely related □Probably related □Possibly related □Unlikely related □Conditional □Unable to assess | □ Yes □ No | |||
| □Self-remission □Remission after treatment □Not remitted □Unclear | □Definitely related □Probably related □Possibly related □Unlikely related □Conditional □Unable to assess | □ Yes □ No | |||
| □Self-remission □Remission after treatment □Not remitted □Unclear | □Definitely related □Probably related □Possibly related □Unlikely related □Conditional □Unable to assess | □ Yes □ No | |||
| □Self-remission □Remission after treatment □Not remitted □Unclear | □Definitely related □Probably related □Possibly related □Unlikely related □Conditional □Unable to assess | □ Yes □ No |