Herbal Supplement Adverse Reaction Reporting Template
Patient Information
Full Name
Age
Gender
Male
Female
Other
Prefer not to say
Supplement Information
Product Name
Manufacturer
Batch/Lot Number
Date Started
Date Stopped
Dosage & Frequency
Adverse Reaction Details
Description of Reaction
Date/Time of Onset
Duration
Actions Taken (e.g. stopped supplement, sought medical attention)
Outcome
Reporter Information
Your Name
Contact (Email/Phone)
Relationship to Patient