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Patient Adverse Event Reporting Card

regarding an adverse reaction and/or lack of efficacy of a medicinal product during clinical use.
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    1. PATIENT INFORMATION

    Sex:

    2. SUSPECTED DRUG INFORMATION
    3. INFORMATION ON THE INDICATION OF THE SUSPECTED DRUG

    Was the suspected drug prescribed to the patient by a doctor?

    Did the patient use the suspected drug without a doctor's prescription?

    4. REPORTER INFORMATION