REACTION INFORMATION

PATIENT INITIALS

GENDER

FEMALE

MALE

COUNTRY

DATE OF BIRTH

Day / Month / Year

AGE

Years

DESCRIBE REACTION(S) (including relevant tests/lab data)

(RELATED SYMPTOMS IF ANY SEPARATED BY COMMAS)

DAILY DOSE(S)

ROUTE(S) OF ADMINISTRATION

INDICATION(S) FOR USE

CONCOMITANT DRUG(S) AND HISTORY

OTHER ADDITIONAL INFORMATION

(CONCOMITANT MEDICATIONS AND OTHER RELEVANT MEDICAL HISTORY)

NAME AND CONTACT DETAILS OF REPORTER

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