Adverse Drug Reaction Information Registration Form

The statement:This report will be submitted to the "direct adverse drug reaction reporting system for drug listing license holders" as required by the state. Please provide the real information. If necessary, our company will arrange professionals to contact you.To provide you with services and support.

Patient Information
Patient Name:
Gender:*
Date of Birth:*
Weight:
Kilogram(Kg)
Contact Information:Please leave at least one contact information*
Mobile phone:

Please fill in "international area code" and "mobile number" respectively herein. The international area code for the USA is as follows:001

Such as:001-8605816666.

Fixed phone:

Please fill in "international area code" and "fixed phone number" respectively herein. The international area code for the USA is as follows: 001

Such as:001-2025408888.

E – mail:
Current Suffered Disease
Disease Name:

Please fill in all the diseases that suffered currently. If there are multiple diseases, please fill in them completely and separate them with punctuation marks, e.g.: hypertension, diabetes mellitus, hepatitis B.

Drug Information of Our Company Used in This Treatment
Drug name:*
Manufacturing enterprise:*

Please fill in the name of the drug manufacturing enterprise. The name of the drug manufacturing enterprise is printed on the medicine boxes and PIL.

Batch number:*

Please fill in the batch number of the drug. The batch number is printed on the medicine boxes and inner package of the drug. If the batch number is unknown, please click “Unknown” in this item.

Strength:

Please fill in the strength of the drug. The strength is printed on the medicine boxes, PIL and inner package of the drug, e.g.: 10mg.

Approval number:

Please fill in the approval number of the drug. The drug approval number is printed on the medicine boxes and PIL, e.g.: Guoyaozhunzi H20110033

Cause of medication:
Administration route:*

Please fill in the administration route, e.g.: oral administration. If there are multiple administration routes, please fill in them completely and separate them with punctuation marks, e.g.: oral administration, vaginal administration.

Medication starting time:
Days of medication:
Usage & Dosage:*

Please fill in the usage & dosage of the drug, e.g.: One tablet at a time and three times a day. Please click in the drop-down box to select the unit of dosage per use, if there is no suitable units to select, please click "other units" in this item, and fill in the corresponding unit name in "other units".

Each time

Each day

time(s)

Add

Drug name Medication days Modify Operation
Combined Medication Information

Combined medication refers to other drugs used in addition to our company's drugs.

Combined Medication:

Filling in example:

Cephalexin tablet: pneumonia.

Adverse Drug Reaction Information
Adverse drug reaction symptoms:*

Please fill in the symptoms of adverse drug reactions (discomfort symptoms) with the use of the drug. If there are multiple adverse drug reactions, please fill in them completely and separate them with punctuation marks, e.g.: nausea, vomiting, fever, rash.

Starting time:*
Occurrence place of adverse drug reaction(s):*
Results of current adverse drug reaction symptoms:*
Recovered time:
Whether the symptoms of adverse drug reaction(s) disappear or alleviate after drug withdrawal or dose reduction?*
After reusing the drug, whether the same adverse drug reaction(s) occur again?*
Description of adverse drug reaction(s) process:*

Please describe the dynamic changes process of adverse drug reactions as detailed as possible. Filling in example:

The patient took xx drug starting from xx year xx month xx day due to xx. On xx year xx month xx day the patient appeared xx adverse drug reaction symptom(s). The patient did xx check (e.g.: blood routine, urine routine, B-ultrasound and etc.) on xx year xx month xx day, and the result is xx. xx measures (e.g.: stop medication, reduce dosage, take therapeutic drugs and etc.) were taken to adverse drug reaction on xx year xx month xx day. The result of adverse drug reaction is xx (e.g.: adverse reaction symptom(s) relieved on xx year xx month xx day, adverse reaction symptom(s) disappeared on xx year xx month xx day and etc.).

Related Important Information
Whether there had any adverse drug reaction(s) with any drug used before?
Please fill in the drug name and the symptoms of the adverse drug reaction(s):

Filling in example:

Cephalexin tablet: rash.

Whether family members had any adverse drug reaction(s) with any drug they used before?
Please fill in the drug name, symptoms of the adverse drug reaction(s) and indicate the relationship between the family and the patient:(e.g.: Patient's father)

Filling in example:

Father, Cephalexin tablet: rash.

Please click according to the actual situation:
Other important information:
Preparer Information
Whether is the patient himself:*
Date of filling:*
Contact Information:Please leave at least one contact information*
Mobile phone:

Please fill in "international area code" and "mobile number" respectively herein. The international area code for the USA is as follows:001

Such as:001-8605816666.

Fixed phone:

Please fill in "international area code" and "fixed phone number" respectively herein. The international area code for the USA is as follows: 001

Such as:001-2025408888.

E – mail:
Other Situations that Need to be Described
Notes:

1、Items with “” in the form are required.

2、please click to view the fill in help.

3、 If you have any questions, please contact us:010-62250419 010-62262389

Identifying code: Figure escape point
Submit

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