Consumer Adverse Reaction Reporting
Occupation
Initials of the Reporter
(e.g. John Doe → JD)
Phone Number
Initials of the Patient
Gender of the Patient
Drug name
Suspected Medication Dosage
Detailed Symptoms
Concomitant Medication
Onset Date
Therapy Duration
Discontinuation
Current Condition
Confirmation by Healthcare Professional (Doctor/Pharmacist)
Causality Assessment by Healthcare Professional
Medical History
