1. Patient Information Patient's Name Age Country/City Date of Birth Sex MaleFemaleOther Email Contact No 2. Adverse Reaction Information Onset Reaction Date Select Appropriate Adverse Reaction Describe Reaction(s) with Relevant Test Lab 3. Suspected Drug Information Generic Name of Suspected Drug(s) Daily Dose Batch No Expiration Date Route of Administration Indication for Use Therapy Dates (From/To) to Therapy Duration Did Reaction Occur After Stopping Drug? YesNo Did Reaction Reappear After Reintroduction? YesNo 4. Other Medications and Relevant History Other Administered Drug(s) and Dates of Administration Other Relevant History (Allergy, Pregnancy, Diagnosis, etc.) 5. Reporter Source PhysicianPharmacistNurseRelativePatientMarketing person
