Our Products
Our Products

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