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Contact Information Online Message Adverse reaction detection

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Telephones Consultation 028-88202608

Adverse reaction detection

Patient information

*Patient name：

*Patient gender： male female

Patient age：

weight：

*Primary disease：

Visiting hospital：

Treatment department：

Medication information

*Name of suspected drug：

*Drug marketing license holder：

*batch number：

Reasons for medication：

Drug usage and dosage：

Medication time：

Name of combined drug：

Name of manufacturer：

batch number：

Process description

*Adverse reaction process description：

*Name of reporter：

*Contact information of reporter：

*Date of completion：

*Do you agree to follow up： yes no

*Verification Code：

remarks

1. The suspected drug was the drug that the reporter thought caused adverse reaction; Concomitant drugs are other drugs used by patients in combination with suspected drugs.

2. At least one item should be filled in the patient information.

3. Recommended reference format for description of adverse reaction process: Patients with a certain disease, a certain month and a certain day in a certain year, what kind of adverse reaction (related symptoms, signs and related examinations) occurs, what measures are taken, and when the adverse reaction is cured or improved (related symptoms, signs and related examinations).

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