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Report adverse reaction

The red marks are required fields.
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:
Finish

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