A. Patient Information
Sex
B. Adverse Reaction
Outcome attributed to adverse reaction(check all that apply)
C, SUSPECTED DRUG PRODUCTS(S)
5. Reaction abated after use stopped or dose reduced.
8. Reaction reappeared after reintroduction
D. Reporter
2. Health professional?
4. Also reported to manufacturer?
E. SUSPECT MEDICAL DEVICE
4. Operator of device
8. Device available for evaluation? (Do not send)

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