2. You will take SX -682 twice a day for every day of two- week period. This drug should be taken in a fasting state, me aning no food 2 hours prior to taking the drug and no food 1 hour after taking the drug. 3. Record the date, the number of tablets that you took, and when you took them. 4. If you have any comments or notice any side effects, ple ase record them in the comment’s column. 5. Please bring this form and your bottles (even it is empty) when you come for your clinic visit. Day Date Oral SX -682 (every 12 hours) Comments (Side effects, reason for missing dose, etc) Morning Dose Evening Do se Time # Tablets Time # Tab lets -14L -13L -12L -11L -10L -9L -8L -7L -6L -5L -4L -3L -2L -1L Participant ’s signature: ___________________________________________________ Abbreviated T itle: STAT Trial Version Date : 08/17/2022 128 16.3.2 Cycles Participant ’s ID _ ________________________ Tr eatment Cycle:_____________________ Participant SX-682 Dose :__________________ Treatment Dates:______________________ INSTRUCTIONS TO THE PARTICIPANT : 1. Complete one form for each cycle on the trial. 2. You will take SX -682 twice a d ay for every day of the cycle. This drug should be taken in a fasting state, meaning no food 2 hours prior to taking the drug and no food 1 hour after taking the drug. 3. Record the date, the number of tablets that you took, and when you took the m. 4. If you ha ve any comments or notice any side effects, please record them in the comment’s column. 5. Please bring this form and your bottles (even it is empty) when you come for your clinic visit. Day Date Oral SX -682 (ev ery 12 hours) Comm ents (Side effects , reason for missin g dose, etc) Morning Dose Evening Dose Time # Tablets Time # Ta blets 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Abbreviated T itle: STAT Trial Version Date : 08/17/2022 129 Day Date Oral SX -682 (ev ery 12 hours) Comm ents (Side effects , reason for missin g dose, etc) Morning Dose Evening Dose Time # Tablets Time # Ta blets 25 26 27 28 Participant ’s signature: ___________________________________________________