Patient Information | |||
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*Age(Y/M/D): | *Gender: Male Female | Original Disease: |
Medication Information | |||
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*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 | |||
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*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 | |||
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Notes: |
Telephone number:800-810-1156 or 400-650-5676 E-mail:adr@bjhanmi.com.cn