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Report adverse reaction

The red marks are required fields.
Patient name
Name: Sex: Male Female Date of birth: Weight(kg):
Contact number: Allergy history:
Information of taking medicine
Drug name: Lot number: Time of taking medicine:
-
Dosage: Route of administration: Reasons of medication:
Drug adverse reaction information
Name of adverse reaction:
Description of adverse reaction process:
Occurrence time of adverse reaction: - Severity reference standard: Severity General

Other than these six items are Non-serious adverse reaction:
1.Causing death. 2.Life threatening. 3.Resulting in hospitalization or prolonged hospitalization. 4.Permanent or significant disability/loss of function. 5.Congenital anomalies/birth defects. 6.lead to other important medical event.

Finish

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