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Adverse reaction information feedback

Gender *

Male Female

Suspect Products

If Attributed to Following Situations (Check All That Apply)

Bogus Drug

Overdose

Paternal Exposures

The Drug Has Exceeded Its Expiration Date

Batch Number Passed the Assay/Test

Batch Number Did Not Pass the Assay/Test

Medication Errors

Misuse

Abuse

Occupational Exposure

Use Beyond the Instruction Manual

N/A

Drug Adjust Treatment *

Unknown

Discontinuing Medication

Reduce Dose

Increase Dosage

Dose Unchanged

Other (Concomitant) Drug Products *

Yes

Adverse Reaction/Event Process Description (Including Symptoms, Signs, And History of Drug Combination, Etc.) And Treatment*

Follow-up Outcome After Drug Adjust Treatment *

Healed

On the mend

Did not on the mend

Unknown

Sequela Occurred

Death

Does the Reaction/Event Symptoms Resolved or Alleviated After Discontinuation or Dosage Reduction *

Yes

Unknown

N/A

Reaction/Event Reappeared After Suspect Products Reintroduction *

Yes

Unknown

N/A

Severity *

Yes

Relevance Evaluation

Relevant

Very Likely

Possible

Perhaps Unrelated

Unable to Evaluate

Gender *

Suspect Products

If Attributed to Following Situations (Check All That Apply)

Drug Adjust Treatment *

Other (Concomitant) Drug Products *

Adverse Reaction/Event Process Description (Including Symptoms, Signs, And History of Drug Combination, Etc.) And Treatment*

Follow-up Outcome After Drug Adjust Treatment *

Does the Reaction/Event Symptoms Resolved or Alleviated After Discontinuation or Dosage Reduction *

Reaction/Event Reappeared After Suspect Products Reintroduction *

Severity *

Relevance Evaluation

Other Information Message Board