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Our Products

ADR

    Required Information


    ABOUT PATIENT

    For Office Use Only
    Report No.




    AgeDOB


    yearsmonthsdays

    Kglbs


    MaleFemale




    ABOUT PROBLEM


    Adverse EventProduct Use ErrorProduct ProblemProblem with different manufacturer of same medicine
    Death (include date)

    Life-threateningHospitalization - initial or prolongedDisability or Permanent DamageCongenital Anomaly/Birth DefectsOther Serious (Important Medical Events)




    The reaction disappearedThe reaction was reducedNo change in the reaction








    YesNo




    ABOUT PRODUCT

    Suspect Drug:













    YesNo

    YesNo

    YesNo




    YesNoDoesn’t Apply


    YesNoDoesn’t Apply




    CONCOMITANT DRUGS:

    (do not mention treatment of the event):

    Brand Name

    Generic name

    Date Person Started Drug

    Date Person Stop Drug




    ABOUT REPORTER:














    FORM MK - 03-01