Post-Marketing Drug Adverse Event Submission
Reporter Name
Reporter Contact Information
Patient Initials or ID
Patient Age
Patient Gender
Female
Male
Other
Drug Name
Drug Dosage / Strength
Batch/Lot Number
Dosing Start Date
Dosing End Date
Adverse Event Description
Adverse Event Onset Date
Actions Taken
Outcome
Recovered
Recovering
Not Recovered
Unknown
Fatal
Relevant Medical History
Concomitant Drugs
Additional Information