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  Name   Birth Date Gender Male  Female  
  Job   Race      
  Weight  (kg)   Height  (cm) Pregnancy Yes  No
If Yes, Specify the week
  Hospital/Health Center   File Number  

Suspected Drugs Information

Other prescribed and Un-prescribed (OTCs) Drugs Information

Herbal Remedies & Vitamins

Description of the ADR: (click to expand)

Seriousness of the ADR (click to expand)

Risk Factors (click to expand)

Relevant laboratory/tissues tests: (click to expand)

Description of Adapted treatment of the ADR: (click to expand)

Previous experience with drug(s) (click to expand)

Suspected drug-ADR relationship (click to expand)

Please, fill in all requested fields.