Rameda Safety Reporting
13844
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Rameda Safety Reporting

    Report Information*


    YesNo

    Reporter Details*


    Patient Information*

    MaleFemale

    Death

    YesNo

    Relevant Medical History

    YesNoYesNoYesNo

    Past Drug Therapy (Not suspected or contaminated drug)

    Lab Test & Investigation

    Adverse Event(s) – Reaction(s)*

    ADR1*

    YesNo

    ADR2

    YesNo

    ADR3

    YesNo

    List of Suspected Drugs*

    Drug 1*

    YesNo

    Drug 2

    YesNo

    Drug 3

    YesNo

    List of Concomitant Drugs*

    Drug 1*

    YesNo

    Drug 2

    YesNo

    Drug 3

    YesNo