Report adverse reaction| Patient Information | |||
|---|---|---|---|
| *Age（Y/M/D）: | *Gender: Male Female | Original Disease: | |
| Medication Information | |||
|---|---|---|---|
| *Suspected Drug（Trade Name/Generic Name）: | Usage and Dosage：times per day, mL/g/capsule/pack each time | Batch Number: | Medication Starting and Ending Time: - |
| Adverse Reaction/Event | |||
|---|---|---|---|
| *Adverse Reaction/Event Symptom: | Occurrence Time: | Adverse Reaction/Event Result (as of the time of report): Recovered Recovering Not improved | |
|
Description of Adverse Reaction/Event: |
|||
| Reporter Information | |||
|---|---|---|---|
| *Contact Number: |
| Notes | |||
|---|---|---|---|
| Notes: |
Telephone number：800-810-1156 or 400-650-5676 E-mail：adr@bjhanmi.com.cn
