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II
III
IV
Sl. No. 9. Reaction abated after drug stopped or dose reduced 10. Reaction reappeared after reintroduction
As per C Yes No Unknown NA Reduced Dose Yes No Unknown NA If reintroduced,
dose
I
II
III
IV
11. Concomitant medical products and therapy dates including self D. Reporter (See confidentiality section)
medication and herbal remedies (exclude those used to treat reaction) 16. Name & Professional Address:
____________________________________________________________
____________________________________________________________
____________________________________________________________
Pin: __________________ E-mail: _______________________________
Mob./Tel. No. with STD code: ___________________________________
UHID/IP No.: ___________________ Speciality: ____________________
Signature: ____________________________________
17. Occupation: 18. Date of this report
(dd/mm/yy)
GH/F54/2016,Rev.01(2017), Page 1 of 2
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