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Name *
Age *
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Address (if available)
Contact Number (if available)
Hospital/facility seen or admitted *
Date of onset *
Duration *
Do you consider the reaction to be serious? *
If you answered "Yes" to the previous question, please indicate the reason/s
Can this be due to Medication Error? *
Generic name *
Brand name
Daily dose *
Route *
Reason/s for using the product (Indication) *
Date started *
Date stopped (if applicable)
Name
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