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ADR FORM (For patients)

Required Information


ABOUT PROBLEM

For Office Use Only
Report No.


Was hurt or had a bad side effect (including new or worsening symptoms)Used a medicine incorrectly which led to a problemNoticed a problem with the quality of the productHad problem after switching from one medicine maker to another maker



Hospitalization - admitted or stayed longerDisability or health problemLife-threateningBirth defectOther serious/important medical incident (please describe)

Death (include date)









Prescription or over-the-counter medicineBiologics, such as human cells and tissues used for transplantation and gene therapiesNutrition products, such as vitamins and minerals, alternative medicines, infant formulas,Other health and OTC products.Medical cosmetics

YesNo




ABOUT PRODUCT


















The reaction disappearedThe reaction was reducedNo change in the reaction





YesNo

YesNo

YesNo

YesNo

YesNo




ABOUT PATIENT



Kglbs

MaleFemale



AgeDOB

yearsmonthsdays












ABOUT REPORTER












FORM MK - 03-02